Quarterly Statement Of Estimated Income Tax Form (Page 2 of 5) in pdf

Form D-1/B

CITY OF BELLEFONTAINE, OHIO

File with Dept. of Taxation

135 N. Detroit St.

DECLARATION OF ESTIMATED CITY INCOME TAX

Bellefontaine, OH 43311-1462

FOR THE CALENDAR YEAR _______

Telephone 937/593-8362

FAX 937/593-8372

DUE ON OR BEFORE APRIL 15TH

NAME AND ADDRESS

METHOD OF PAYMENT

Check

CREDIT CARD EXPIRATION DATE

(Amount Authorized)

PHONE NUMBER

HOME

WORK

CARD HOLDER SIGNATURE

If name or address is incorrect, make necessary changes

PURPOSE OF DECLARATION. The purpose of the declaration is to provide a basis for paying currently any income tax due from individuals and business enterprises

as specified on Instructions. Every taxpayer required to file a Declaration of Estimated Bellefontaine Income Tax must also file an annual income tax return after the close

of the taxable year, and pay any balance of tax due over and above the total withheld from wages and/or the amount paid in installments as estimated tax. Any claim of

refund due to overpayment must be made when filing the annual return.

Check your status as a taxpayer: Resident

Non Resident

Employee

Partner

Professional

Partnership

Corporation

Proprietors

Computation of Estimated Tax:

1. Total estimated income subject to tax. ........................................................................................................................ $ _________________

2. Estimated Tax due: 1.333% of Line 1 .......................................................................................................................... $ _________________

3. Less Credits (Amount carried over from previous year) ............................................................................................. $ _________________

4. Net Tax Due: ................................................................................................................................................................ $ _________________

5. Amount paid with this Declaration ............................................................................................................................... $ _________________

6. Balance of tax payable ................................................................................................................................................ $ _________________

MAKE REMITTANCE TO THE “CITY OF BELLEFONTAINE”

The undersigned declares this to be a true, correct and complete Declaration of Estimated Bellefontaine Income Tax for the period stated.

(DATE)

(SIGNATURE AND TITLE)

(DATE)

(SIGNATURE AND TITLE)

ONE-FOURTH OF UNPAID BALANCE MUST ACCOMPANY THIS RETURN

All businesses and/or corporations subject to Bellefontaine Tax must file a Declaration of Estimated Tax. Failure to comply with this

regulation will result in penalty and interest charges.