Individual Tax Return Form - City Of Blue Ash - 2011
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1
2Individual Tax Return
City of Blue Ash
Income Tax Office
2011
4343 Cooper Road,
Blue Ash, OH 45242
OR
Phone: (513) 745-8516
FISCAL PERIOD _________ TO _________
Fax: (513) 745-8651
Website:
April 17, 2012
Calendar Year Taxpayers file on or before
Email:
THIS SPACE IS FOR OFFICIAL USE ONLY
th
th
Fiscal Year Due on 15
Day of 4
Month After Year End
Taxpayer’s SSN ______-_____-________
Spouse’s SSN _______-_____-________
Spouse’s Name__________________________
Phone# ______________Other#_____________
If you have moved since your last filing, give date:
Into Blue Ash________ Out of Blue Ash________
Should your account be inactivated?
Reason: ________________________________
IF INFORMATION ABOVE IS INCORRECT, PLEASE MAKE CORRECTIONS
Part A
Tax Calculation
Total Qualifying Wages (Attach W-2 Forms) For multiple W-2s complete Worksheet A on page 2………………
1.
$
2.
Less Employee Deductions (Attach Form 2106)………………….………………………………………………………
$
Taxable Wages Before Adjustment. (Line 1 minus Line 2) …………..………………………………………..……..…
3.
$
4.
Less Nontaxable Income (part year or non-residents only) (provide calculations)…………………………………….
$
Taxable Qualified Wages (Line 3 minus Line 4)………………………………………………………...…………………
5.
$
Other Income or (Loss) From Federal Schedules C, E, F, K-1, 1099-MISC (See Worksheet B Line 6)……………
6.
$
7.
Blue Ash Taxable Income (Line 5 plus Line 6) Losses on Line 6 do not offset W-2 Income from Line 5……..
$
Blue Ash Income Tax (Multiply Line 7 by 1.25% [.0125])………………………………………………………………...
8.
$
Blue Ash Tax Withheld (per W-2s or see worksheet A)………………….
9 a.
$
Estimates Paid (including credit from previous year)……………………..
9 b.
$
Credit for Other City Taxes Paid (Limitations apply – see instructions)..
9 c.
$
Total Payments and Credits (Lines 9a + 9b + 9c)…….…………………………………………………………………..
10.
$
Tax Due (Subtract Line 10 from Line 8)………………………………………………………………………………….
11.
$
Overpayment (Line 10 greater than Line 8)………………………………
12.
$
(Amounts less than $1.00 will not be refunded)…
13.
Amount to be Refunded
$
Amount to be Credited to Next Year…………………………….………..
14.
$
Part B
Declaration of Estimated Tax for 2012–
Mandatory if estimated liability is $100.00 or more
Total estimated income subject to tax………………………………………………………………………………………
15.
$______________________
Blue Ash Income Tax Declared (Multiply Line 15 by 1.25% [.0125])…………………………………………………...
16.
$______________________
Estimated Local Taxes Withheld from Wages…...(Not to exceed 1.25% of those wages taxed)…………………..
17.
$______________________
Net Tax Due (Line 16 less Line 17) STOP if this amount is zero...……………………………………………………..
18.
$
Declaration Due (25% of Line 18) …………………………………………………………………………………..……..
19.
$______________________
Less credits (from Line 14 above)…………………………………………………………………………………………...
20.
$______________________
Net estimated tax due if Line 19 minus Line 20 is greater than zero*………………………………………….……..
21.
$
TOTAL AMOUNT DUE—Line 11 plus Line 21 (Make checks payable to the Blue Ash Income Tax Office)
22.
$
Submit copies of all related W2’s, other City returns, Form 1040 and other Federal schedules.
FOR TAX OFFICE USE ONLY
Tax $__________ Penalty $__________ Interest $___________ Late ______ months
TOTAL DUE $__________________
st
*Subsequent estimated payments are due by the 31
of July, October and January.
Check here if we may contact the tax preparer with questions regarding the preparation of this return.
The undersigned declares that this return (and accompanying schedules) is a true, correct and complete return for the taxable period stated
and that the figures used herein are the same as used for Federal Income Tax purposes.
___________________________________________ ____________
___________________________________________ ______________
SIGNATURE OF TAXPAYER
SIGNATURE OF PERSON PREPARING IF OTHER THAN TAXPAYER
DATE
DATE
_________________________________________________________
________________
__________________________________________________________
___________________
SIGNATURE OF SPOUSE
NAME AND ADDRESS OF PREPARER
PHONE NUMBER
DATE
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