Form Ir-25 - City Income Tax Return For Individuals - 2016

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2016
Staple W-2’s to the back of this page
IR-25
City of Westerville, Income Tax
City Income Tax Return For Individuals
Check the appropriate box if:
Primary Social Security Number
First name and Middle Initial
Last Name
Line 6B for this return to be
considered a valid refund request)
Spouse's Social Security Number
tax year
AMENDED
If a joint return, spouse's first name and initial
Last Name
□
□
Filing Status:
Did you change residence
Yes
No
during 2016?
Home Address (number and street)
Single
If YES, enter date of move __________
□
□
Should your account be inactivated?
Yes
No
Married-Filing Jointly
If YES, explain ________________________
Married-Filing Separately
□
□
City
Did you file a City return in 2015?
Yes
No
State
Zip Code
Attach all forms and applicable Federal schedules and/or documentation to the back of this return.
Occupation or nature of business
Employer(s) and address where work performed
TAXABLE WAGES
Part A
(+)
Trade Name
(+)
City of Employment #1
ADJUSTMENTS
City of Employment #2
(-)
City of Employment #3
NET WAGES (enter in Column B below)
(=)
City of Residence
Part B
TAX CALCULATION
A Declaration of Estimated City Tax (form Q-1) is REQUIRED for all individuals whose tax is not fully withheld.
TAX
Column B
Column C
Column D
Column E
Column F
Column G
Column A
RATE
LESS TAX WITHHELD (W-2)
CITY
INCOME FROM WAGES,
INCOME FROM NET
TOTAL NET
TAX DUE
NET TAX DUE
PAID BY A PARTNERSHIP OR
SALARIES, COMMISSIONS, ETC.
PROFITS, RENTS AND
TAXABLE INCOME
PAID DIRECTLY TO CITY WHERE
(SEE NET WAGES)
INCOME WAS EARNED
OTHER TAXABLE INCOME
Limited to 2.0%
WESTERVILLE
2.0%
1
1. TOTAL NET TAX DUE (TOTAL OF COLUMN G)
..................................................................................................................................................
2
2. LESS CREDITS FOR ESTIMATED TAX PAYMENTS AND OVERPAYMENT FROM PRIOR YEAR RETURN ONLY .......
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: 15% $
+ INTEREST 5% $
+ LATE CHARGE $
... = ......................................................
4
(see instructions)
(see instructions)
(see instructions)
5. TOTAL AMOUNT DUE (ADD LINES 3 AND 4). NOTE: NO PAYMENT IS DUE IF AMOUNT IS $10.00 or less……................................................
5
6
6. OVERPAYMENT CLAIMED (IF LINE 2 EXCEEDS LINE 1) .............................................................................................
6A
A. Enter the amount from Line 6 you want
CREDITED
(Must be greater than $10.00) .................
6B
B. Enter the amount from Line 6 you want
REFUNDED (must be greater than $10.00)
(COMPLETE
Part C
INCOME FROM SOURCES OTHER THAN WAGES, SALARIES, COMMISSIONS, ETC.
REVERSE SIDE OF
FORM FIRST)
Column H
Column I
Column J
Column K
CITY
INCOME (OR LOSS) FROM
OTHER INCOME FROM
TOTAL OTHER INCOME
INSERT APPLICABLE CITIES
RENTAL INCOME (OR LOSS) FROM
BELOW
PART E OR SCHEDULE Y
PART F (SECTION 2)
(OR LOSS)
PART F (SECTION 1)
WESTERVILLE
NO
Do you want to allow another person to discuss this matter with the City of Westerville?
(see
Yes
Complete the following
Third
instructions)
(
)
Party
Designee’s
Phone
►
No.
SSN
Designee
Name
The undersigned declares that this return (and accompanying schedules) is a true, correct and complete return for the
Signature
MAILING INFORMATION
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.
Sign
Your
Mail to: City of Westerville
►
Date
Here
Signature
PO Box 130
If a joint return
Spouse’s
Westerville OH 43086-0130
Signature ►
Both must sign
Date
Make payable to: City of Westerville
Paid
Phone: 614-901-6420
Signature
Date
PTIN
Preparer’s
Fax:
614-901-6820
►
Phone No. (
)
Use Only

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