Form Ir - Mt. Healthy Income Tax Return - 2009
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3MT. HEALTHY
FORM IR
2009
Make check or money order
FILE WITH
INCOME TAX RETURN
Mt. Healthy Tax Dept.
PAYABLE TO:
7700 Perry Street
CITY OF MT. HEALTHY
Mt. Healthy, OH 45231
FILING REQUIRED EVEN IF NO TAX DUE
513-728-3181
DUE ON OR BEFORE
APRIL 15, 2010
TAXPAYER NAME(S) AND ADDRESS
TAXPAYER SOCIAL SECURITY NUMBER
_____________________________________
_______________________________________
SPOUSE SOCIAL SECURITY NUMBER
_____________________________________
_______________________________________
_____________________________________
TELEPHONE: Business __________________
TELEPHONE: Home ____________________
IF YOU ARE A NEW RESIDENT, FILING THE FIRST TIME OR YOU MOVED SINCE FILING YOUR 2009 TAX RETURN, PLEASE FURNISH YOUR
CURRENT MAILING ADDRESS AND DATE OF MOVE.
MOVED INTO MT. HEALTHY: _______________________
MOVED OUT OF MT. HEALTHY: _______________________
FILING INSTRUCTIONS ON PAGE 2 OF THIS FORM
NOTE: Page 2 must be completed if you have taxable rental property or business income.
1.
TOTAL OF ALL MEDICARE WAGES (BOX 5) (ATTACH ALL W-2’S)
$______________________
(DEFERRED COMP., PENSION PLANS, 401K, ETC. ARE TAXABLE IN YEAR EARNED)
2.
TOTAL OTHER TAXABLE INCOME OR DEDUCTIONS: ENTER AMT. SHOWN ON LINE 21 (PAGE 2)
$_________________________
3.
TOTAL TAXABLE INCOME: LINE 1, PLUS LINE 2
$_________________________
4.
MT. HEALTHY TAX 1.5% OF LINE 3
$_________________________
5.
TAX CREDITS (NOTE: NO CREDIT CAN BE GIVEN WITHOUT PROPER VERIFICATION)
A.
TAX WITHHELD BY EMPLOYER FOR CITY OF MT. HEALTHY
$_________________________
B.
ENTER 2009 TOTAL ESTIMATED TAX PAID TO CITY OF MT. HEALTHY
$_________________________
C.
ENTER 2009 TAXES PAID CITY OF _______________________________________
$_________________________
MAXIMUM OF 1.25% (SEE INSTRUCTIONS FOR CREDIT COMPUTATION)
D.
TOTAL TAX CREDITS (ADD TOGETHER LINES 5A THROUGH 5C)
$_________________________
6.
IF LINE 4 IS GREATER THAN LINE 5D PAYMENT OF BALANCE MUST ACCOMPANY THIS RETURN
$__________________________
2009 tax due and payable by 4/15/10
TAX $____________________
PENALTY $____________________
INTEREST $____________________
TOTAL $_________________
7.
OVERPAYMENT TO BE REFUNDED $__________
OR CREDITED $__________ TO NEXT YEAR ESTIMATE
NOTICE: By law, all refunds and credits, in excess of $10.00 are being reported to IRS
DECLARATION OF ESTIMATED TAX FOR THE YEAR 2010
8.
TOTAL ESTIMATED 2010 INCOME $_______________ MULTIPLY BY RATE OF 1.5% = TOTAL 2010
ESTIMATED TAX
$_________________________
A.
ESTIMATED TOTAL TAXES TO BE WITHHELD BY EMPLOYER(S) FOR CITY OF
MT. HEALTHY
$_________________________
B.
ESTIMATED TOTAL TAXES, NOT OVER 1.25% WITHHELD FOR OR PAYABLE TO
OTHER CITIES
$_________________________
C.
TOTAL CREDITS (8A + 8B)
$_________________________
9.
NET ESTIMATED TAX DUE FOR 2010 (LINE 8 MINUS LINE 8C)
$_________________________
10.
AMOUNT DUE WITH THIS FORM (NOT LESS THAN ¼ OF LINE 9)
$_________________________
A.
LESS PRIOR YEAR OVERPAYMENT (CREDIT FROM LINE 7)
$_________________________
ST
11.
NET TAX DUE WITH THIS RETURN FOR 1
QUARTER 2010 (DUE BY APRIL 15, 2010)
$_________________________
IF PAYING WITH MASTERCARD OR VISA, FILL IN INFORMATION ON PAGE 3 OF THIS FORM
12.
AMOUNT ENCLOSED (LINE 6) $____________ + (LINE 11) $____________ = TOTAL AMOUNT DUE
$_________________________
I CERTIFY THAT I HAVE EXAMINED THIS RETURN (INCLUDING ACCOMPANYING SCHEDULES AND STATEMENTS) AND TO THE BEST OF MY KNOWLEDGE
AND BELIEF IT IS TRUE, CORRECT AND COMPLETE. IF PREPARED BY OTHER THAN TAXPAYER THE DECLARATION IS BASED ON ALL INFORMATION OF
WHICH PREPARER HAS ANY KNOWLEDGE.
_____________________________________________________________
_______________________________________________________________
Signature of person preparing if other than taxpayer
Date
Signature of Taxpayer or Agent (Required)
Date
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