Extension Request Form-City Of Blue Ash

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City of Blue Ash
Income Tax Office
4343 Cooper Road
(513) 745-8516
Blue Ash, Ohio 45242-5699
Fax: (513) 745-8651
EXTENSION REQUEST FORM
Type or print taxpayer(s) FID number or Blue Ash Tax Account Number, name, address and how payment should be applied below. Please
be sure to include 2 copies and a self-addressed stamped envelope to ensure return of your request.
DATE OF REQUEST: ___________________
FOR TAX YEAR: _______________________
EXTENSION REQUESTED TO (DATE): ____________________
PAYMENT AMOUNT ENCLOSED: ______________
F.I.D.# or
PAYMENT DUE
DECLARATION
PAYMENT DUE
BLUE ASH TAX
TAXPAYER NAME
ADDRESS
ON EXTENDED
FOR NEXT TAX
ON NEXT
ACCT. NUMBER
TAX YEAR
YEAR
TAX YEAR
FOR TAX OFFICE USE ONLY
□ EXTENSION REQUEST GRANTED TO: ___________________
□ NO SUCH ACCOUNT NAME OR NUMBER ESTABLISHED
□ EXTENSION REQUEST GRANTED BY: ___________________
□ OTHER
_____________________________________________
TAX PREPARER’S INFORMATION (please print):
Preparer’s Name: ________________________________
Preparer’s Phone #: _____________________
Preparer’s Address: ______________________________
Preparer’s Fax #:
_____________________
Preparer’s City, State, Zip Code: ____________________________________
Revised (01/2010)

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