City Income Tax Return For Individuals

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Staple W-2’s to the back of this page
2011
IR-22
City of Columbus, Income Tax Division
City Income Tax Return For Individuals
Primary Social Security Number
Check the appropriate box if:
Your first name and initial
Last name
-I
REFUND
(An amount must be placed
in Line 6B for this return to be considered
a valid refund request).
Last name
If a joint return, spouse’s first name and initial
Spouse’s Social Security Number (if joint)
AMENDED
tax year
.
Home address (number and street).
Apt. no
Single
Married-Filing Separately
Filing Status:
Married-Filing Jointly
•Did you change residence during 2011?
YES
NO
City, town or post office, state, and ZIP code.
If YES, enter date of move
Part A
•Should your account be inactivated?
YES
NO
Attach all forms W-2 and applicable Federal schedules and/or documentation - TO BACK
If YES, explain
Employer(s) and address where work performed
Part A
Did you file a City return in 2010?
YES
NO
•
TAXABLE WAGES
(see Page 2 for Adjustments to Taxable Wages)
•City(ies) of Employment/Income #1
#2
(+)
$
•City of Residence
•Occupation or nature of business:
City
Tax
City
Tax
(+)
$
City
Code
Rate
City
Code
Rate
Harrisburg
(UFR)
16
1.0%
Columbus
01
2.5%
ADJUSTMENTS
Brice
14
2.0%
Marble Cliff
(UFR)
13
2.0%
(-)
$
Canal Winchester
11
2.0%
Obetz
10
2.0%
Groveport
09
2.0%
UFR =
Universal Filing Requirement of all
NET WAGES (enter in Column B below)
(=)
$
residents of this community.
Part B
2011 TAX CALCULATION
If you file with more than two cities, call 645-7370 and request Form IR-25.
Column A
Column B
Column C
Column D
Column E
Column F
Column G
C
TAX
LESS TAX WITHHELD (W-2),
INCOME FROM
INCOME FROM NET
TOTAL
O
TAX DUE
NET TAX DUE
WAGES, SALARIES,
PROFITS, RENTS
RATE
PAID BY A PARTNERSHIP OR
CITY
D
NET TAXABLE
PAID DIRECTLY TO CITY
COMMISSIONS ETC.
AND OTHER TAXABLE
E
INCOME
(SEE NET WAGES)
INCOME (Pg. 2)
WHERE INCOME WAS EARNED
*ALTERNATE CITY
*
ALTERNATE CITY LINE - see instructions
1
$
1. TOTAL NET TAX DUE (TOTAL OF COLUMN G) .................................................................................................................................
2. LESS CREDITS FOR ESTIMATED TAX PAYMENTS AND OVERPAYMENT FROM PRIOR YEAR RETURN ONLY.......
2
$
3
$
3. BALANCE DUE (LINE 1 LESS LINE 2). If Line 2 is greater than Line 1, enter amount (in brackets) here and carry to Line 6. .....................
4. PENALTY: 10% $_____________ + INTEREST $_____________
= .................................................................................................
4
$
(see instructions)
(see instructions)
5
$
5. TOTAL AMOUNT DUE (ADD LINES 3 AND 4). NOTE: NO PAYMENT IS DUE IF AMOUNT IS LESS THAN $1.00
    
6
$
6. OVERPAYMENT CLAIMED (IF LINE 2 EXCEEDS LINE 1)...............................................................................
CARRY THIS AMOUNT TO LINE 8
    
6A $
A.
...
ENTER THE AMOUNT FROM LINE 6 YOU WANT
CREDITED
TO YOUR NEXT YEAR TAX ESTIMATE
B.
6B
REFUNDED
    
$
ENTER THE AMOUNT FROM LINE 6 YOU WANT
(MUST BE GREATER THAN $1.00)
Part C
2012 DECLARATION OF ESTIMATED TAXES
A declaration of estimated tax is required if all taxes are not fully withheld.
Column H
Column I
Column J
Column K
Column L
Column M
Column N
C
ESTIMATED INCOME FROM
ESTIMATED INCOME FROM
TOTAL
TAX
LESS TAX TO BE WITHHELD
O
ESTIMATED
CITY
ESTIMATED
(W-2) PAID BY A PARTNERSHIP
WAGES, SALARIES,
NET PROFITS, RENTS AND
D
NET ESTIMATED
RATE
NET TAX DUE
OR PAID DIRECTLY TO CITY
TAX DUE
OTHER TAXABLE INCOME
COMMISSIONS - ETC.
E
INCOME
WHERE INCOME WAS EARNED
*ALTERNATE CITY
7
$
7. TOTAL NET ESTIMATED TAX DUE (TOTAL OF COLUMN N) ...............................................................................................................
8. OVERPAYMENT CREDITS FROM PREVIOUS YEAR RETURN (FROM LINE 6A) ..............................................
$
8
9. TOTAL CREDITS (AMOUNT FROM LINE 8)...................................................................................................
9
$
10. UNPAID BALANCE DUE (SUBTRACT LINE 9 FROM LINE 7)..........................................................................
10
$
11. LESS AMOUNT PAID WITH THIS DECLARATION (A minimum 25% of Line 7 due now).........................................................................
11
$
12. ESTIMATED TAX BALANCE PAYABLE IN EQUAL INSTALLMENTS EACH QUARTER (Line 10 less Line 11) ..........
12
$
13. TOTAL (ADD LINE 5 [if positive] AND LINE 11)
     13
$
Third
Do you want to allow another person to discuss this matter with the City of Columbus?
(see instructions)
YES Complete the following
NO
Party
Designee’s
Phone
(
)
SSN
Designee
    
Name
No.
SIGNATURE
MAILING INFORMATION
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 are the same as used for federal income tax purposes and understands that this
information may be released to the tax administration of the city of residence and the I.R.S.
NO Payment Enclosed:
Sign
Your
PRINT
Mail to:
Columbus Income Tax Division
Here
    
Signature
Date
PO Box 182437
If a joint return,
Spouse’s
Columbus, Ohio 43218-2437
    
Date
both must sign.
Signature
Payment Enclosed:
Paid
RESET FORM
SSN/EIN
Make payable to: CITY TREASURER
Preparer’s
Date
Signature
    
Mail to:
Columbus Income Tax Division
Use Only
(
)
Phone No.
PO Box 182158
Rev. 10/12/11
Columbus, Ohio 43218-2158

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