Income Tax Return Form Page 2

CITY OF IRONTON, OHIO

INCOME TAX RETURN - INDIVIDUAL OR BUSINESS

YEAR

CALENDAR YEAR _______ FISCAL YEAR _______

RESIDENCY STATUS: _______ RESIDENT _______ NON-RESIDENT PART YEAR RESIDENT - FROM _______ TO _______

DUE BY APRIL 15 OF EVERY YEAR -- FILING IS REQUIRED EVEN IF NO TAX IS DUE

TAXPAYERS NAME AND ADDRESS:

ACCOUNT NUMBER:

SOCIAL SECURITY NUMBERS:

TAXPAYER

SPOUSE

BUSINESS / FEDERAL ID

PAGE 2 MUST BE COMPLETED IF YOU HAVE TAXABLE RENTAL PROPERTY OR BUSINESS INCOME.

1.

BOX 5 MEDICARE

WAGES, SALARIES, TIPS AND OTHER EMPLOYEE COMPENSATION (DEFERRED INCOME OF ANY KIND MUST BE INCLUDED………………

1 $

FOR CITY TAX PURPOSES) ATTACH ALL W-2'S AND COPY OF FEDERAL RETURN

2. OTHER TAXABLE INCOME FROM FEDERAL SCHEDULE C, E, K-1, 1099-MISC - ATTACH ALL SCHEDULES

……………………………………….

2 $

3. IF YOU, THE TAXPAYER ARE A FULL-TIME STUDENT/RESIDENT UNDER THE AGE OF 26 - APPLY THE STUDENT EXEMPTION -$3000.00..……………… ……………….

3 $ -

* ATTACH COPY OF STUDENT INFORMATION AND I.D. FOR THE STUDENT EXEMPTION

4. TAXABLE INCOME: LINE 1 PLUS LINE 2 MINUS LINE 3 IF APPLICABLE

……………………………………………………………….

4 $

5. IRONTON TAX LIABILITY ( 1% OF LINE 4)

……………………………………………………………………………….

5 $

6. CREDITS (Each W-2 stands independent)

A. IRONTON INCOME TAX WITHHELD BY EMPLOYER(S)

……………………………………………………..

6A $

B. ESTIMATED TAXES PAID TO IRONTON

……………………………………………………..

6B $

C. ** 1/2 % RECIPROCITY FOR PAYING ANOTHER MUNICIPAL INCOME TAX - CITY WHERE WITHHELD ________________

………

6C $

**1ST QTR 2012 LAST

1ST QTR 2012 ONLY!

THE RECIPROCITY IS NOT BASED UPON THE AMOUNT PAID TO THE OTHER MUNICIPALITY BUT THE AMOUNT OWED TO IRONTON ON THE WAGES EARNED IN SAID CITY

EX. WAGES EARNED IN OTHER CITY (BOX 5 ON W-2) X 1% DIVIDED BY 4 WILL BE YOUR PER QTR AMT., DIVIDED BY 2 WILL BE RECIP. NO COUNTY TAXES OR USER FEES, ONLY MUNICIPAL TAX

D. PRIOR YEAR OVERPAYMENTS

……………………………………………………..

6D $

E. TOTAL CREDITS (ADD A, B, C & D)

……………………………………………………………………….

6E $

7.

IF LINE 5 IS GREATER THAN LINE 6E PAYMENT OF BALANCE MUST ACCOMPANY THIS RETURN UNLESS IT IS UNDER $1.00:

TAX DUE

LINE 5 MINUS 6E

$

* A. LATE FILING PENALTY-FROM APRIL 16 & 1ST NOTICE IS $25.00, 2ND NOTICE - $50.00, 3RD/ATTORNEY NOTICE-$100.00

7A $

* B. PENALTY - 1-1/2% PER MONTH OF AMOUNT SHOWN ON LINE 7 (IF NOT PAID BY APRIL 15)

7B $

* C. INTEREST - 1-1/2% PER MONTH OF AMOUNT SHOWN ON LINE 7 (IF NOT PAID BY APRIL 15)

7C $

D. TOTAL AMOUNT DUE - PAY IN FULL WITH RETURN

7D $

8.

OVERPAYMENT, IF OVER $1.00, TO BE REFUNDED $__________________ OR CREDITED $___________________ TO NEXT YEAR ESTIMATE

NO PAYMENT OR REFUND / CREDIT FOR AMOUNT LESS THAN $1.00

NOTICE: BY LAW, ALL REFUNDS AND CREDITS, IN EXCESS OF $10.00 ARE BEING REPORTED TO THE IRS

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 A PERSON OTHER THAN TAXPAYER, THE DECLARATION BASED ON

ALL INFORMATION OF WHICH PREPARER HAS ANY KNOWLEDGE.

Signature of Person Preparing if Other than Taxpayer

Date

Signature of Taxpayer or Agent

Date

Spouse's Signature (If Joint Return)

Date

Address

Phone Number

*I (we) authorize the Income Tax Department to discuss this return and enclosures with the preparer above……. Initial here __________

MAKE CHECK OR MONEY ORDER PAYABLE TO:

DECLARATION OF ESTIMATED IRONTON, OHIO CITY INCOME TAX

IRONTON INCOME TAX

1 TOTAL ESTIMATED INCOME SUBJECT TO IRONTON INCOME TAX ……………………..

P.O. BOX 704, 301 SOUTH 3RD STREET

2 IRONTON INCOME TAX (1% OF AMOUNT SHOWN ON LINE 1)………………………..

IRONTON, OHIO 45638

3 LESS OVERPAYMENT CREDIT FROM PREVIOUS YEAR ……………………………….

PH: 740-532-9241 FAX 740-533-6104

4 NET ESTIMATED TAX ……………………………………………………….

5 AMOUNT DUE WITH DECLARATION (1/4 OF LINE 4) ……………………………….

Note: 1/4 of Declaration Payment is Due April 15th. Quarterly Payments Due July 15, October 15 & January 15.