Heath Individual Tax Return Form - Heath Income Tax Bureau - 2012
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FOR OFFICE USE ONLY
HEATH INCOME TAX BUREAU
2012 HEATH INDIVIDUAL TAX RETURN
OFFICE (740) 522-3427
FILING IS REQUIRED WHETHER OR NOT TAX IS DUE AND RECEIVED
1287 HEBRON RD.
HEATH, OHIO 43056-1096
IN OUR OFFICE OR POSTMARKED NO LATER THAN APRIL 15TH
AMT. REC.
DATE REC.
CASH
CHECK
#
CAP
ISSU.
BY.
AUD.REQ. Y
N
COPY MAILED DATE
BY
LETTER MAILED DATE
BY
TAXPAYER SOCIAL SECURITY #
SPOUSE SOCIAL SECURITY #
CORRECT NAME AND ADDRESS ABOVE IF WRONG.
PHONE #
IF ALL INCOME IN 2012 WAS NON-TAXABLE, COMPLETE THIS SECTION (See INFORMATION FILING /Gen. Instruction Page).
I AM RETIRED AND HAVE NON-TAXABLE INCOME OF
SOCIAL SECURITY/PENSION
INTEREST/DIVIDENDS
DATE MOVED IN OR OUT OF HEATH
I HAD NON-TAXABLE INCOME OF
ACTIVE MILITARY PAY
UNEMPLOYMENT
DISABILITY
ADC
IN
OUT
NOTE: IF YOU HAD NO OTHER SOURCES OF INCOME IN 2012 - STOP HERE, SIGN, DATE AND MAIL YOUR RETURN.
ATTACH ALL APPROPRIATE W-2’S, FEDERAL
SECTION A INCOME
1040, SCHEDULES, EXPLANATIONS ETC.
TAXPAYER USE
OFFICE USE
1.
Total W-2 wages. ..........................................................................................................................................
1
1
1a. Total Adjustments (Page 2, Line A3) ............................................................................................................
1a
1a
2.
PAGE 2 INCOME SECTION I, LINE 6 ........................................................................................................
2
2
3.
INCOME SUBJECT TO HEATH TAX (Line 1 minus line 1a, plus Line 2)
......................................................
3
3
$0
4.
HEATH INCOME TAX - 1.5% OF LINE 3
......................................................................................................
4
4
SECTION B CREDITS
TAX CREDITS
TAX CREDITS
5.
2012 Estimated tax paid to Heath
DO NOT EXCEED 1.25% CREDIT
5
5
6.
HEATH TAX WITHHELD (W-2 “Local Tax”)
INCOME $
x 1.5% ..........................
6
6
7.
HEATH TAX WITHHELD
INCOME $
x 25% ..........................
7
7
8.
ALL OTHER CITIES (NOT TO EXCEED 1.25%)
INCOME $
x 1.25% ........................
8
8
INCOME $
x
% ..................
INCOME $
x
% ..................
9.
TOTAL CREDITS (Add Lines 5, 6, 7,
8)..........................................................................................................
9
9
$0
10. If Line 4 is greater than Line 9, enter difference. Balance due ....................................................................
10
10
11. Assess $25.00 for Delinquent Final Filing _______ and Interest (1.5% per month) _______ (Due Date 4-15-13)
2012 Estimated Tax Penalty $5.00 per quarter _______ ..............................................................................
11
11
$0
12. TOTAL DUE Make check payable to Heath Income Tax. (Payments under $5.00 are not required) ..........
12
12
13. If Line 9 is greater than Line 4 resulting in overpayment, please indicate if you desire Refund __________
or credit to 2013 tax ______. (Overpayments under $5.00 are not refunded nor carried forward) ..............
13
13
SECTION C DECLARATION OF ESTIMATED TAX FOR 2005
SECTION C DECLARATION OF ESTIMATED TAX FOR 2013
Required where tax due exceeds $100.00 to Avoid Penalty Charges of $5.00 per quarter.
14. Total income subject to tax .......... $______________________. Multiply by tax rate of 1.5% ......................
14
14
15. Tax withheld by employer (Do not exceed 1.25%) ......................................................................................
15
15
16. 2013 Net tax due (Line 14 less 15) ..............................................................................................................
16
16
17. Divide Line 16 by 4 ......................................................................................................................................
17
17
18. Carryover from prior year. (Line 13, if carryover indicated) ..........................................................................
18
18
19. Subtract Line 18 from Line 17 (Pay this amount. If less than zero, enter zero) ..........................................
19
19
20. PENALTY ......................................................................................................................................................
20
20
21.
Total payment (Add Lines 12, 19, and 20) (Payments under $5.00 are not required)
..................................
21
21
THE UNDERSIGNED DECLARES THAT THIS RETURN IS TRUE, CORRECT AND COMPLETE FOR TAX YEAR 2012.
If this return was prepared by a tax practitioner, check here if we may contact him/her directly with questions regarding the preparation of this return.
Tax Preparer’s Signature
Date
Your Signature
Date
Social Security Number (ID Number)
Phone
Spouse Signature
Phone
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