Quarterly Statement Of Estimated Income Tax Form (Page 4 of 5) in pdf

FORM TR/D/B

CITY OF BELLEFONTAINE, OHIO

135 N. DETROIT ST.

BELLEFONTAINE, OHIO 43311-1463

Check your status as a tax payer:

TELEPHONE (937) 593-8362

FAX (937) 593-8372

Resident

Full Yr

INCOME TAX RETURN (FORM TR)

Part Yr

FILE WITH THE DEPT. OF TAXATION BY APRIL 15TH

If Moved During Year Of This Return Give Date Of Move

FOR THE CALENDAR YEAR

INTO CITY

OUT OF CITY

IF PARTIAL YEAR OR FISCAL PERIOD

Cashier’s Validation

GIVE DATES:

THRU

Federal I.D. No.

If Name or Address is incorrect, Make Necessary Changes

❑

Is this a final return?

Yes

Explain:

NOTE: TAX RATE 1.333%

ALL FEDERAL

SCHEDULES MUST

Tax return for (Check One)

Did you file a city

Has a return been previously

BE INCLUDED

❑

Corporation

S-Corporation

Estate

return last year?

filed using this number?

❑

Partnership

Fiduciary

Trust

Yes

1. Taxable Income from Federal Return (ATTACH COPY OF FEDERAL RETURN) From Form

Line

................. 1

2. Adjustments (From Schedule X) ................................................................................................................................................................... 2

3. Taxable Income before allocation (Line 1 plus/minus Line 2) ....................................................................................................................... 3

4. Allocation Percentage (From Schedule Y) .................................................................................................................................................... 4

5. Bellefontaine Taxable Income (Multiply Line 3 by Line 4) ............................................................................................................................. 5

6. Multiply Taxable Income by 1.333% ........................................................................................ 6. TAX AMOUNT BEFORE ANY CREDITS.

7. Credits:

(A) Payments made on Declaration of Estimated Tax .............................................................................. A

(Including prior year overpayment)

(B) Other Credits (explain) ........................................................................................................................ B

7(C) TOTAL CREDITS

8. Balance Due (Line 6 less Line 7 (C)) ............................................................................................................................................................ 8

9. Add Interest of 18% of Line 8 AND Penalty of:

$25.00 if filed between April 16th and July 15th OR $50.00 if filed July 16th or later ................................................................................. 9

10. Add Late Filing Fee of:

$25.00 if filed between April 16th and July 15th OR $50.00 if filed July 16th or later ............................................................................... 10

11. Total amount due (Add Lines 8, 9 and 10)

PAYMENT MUST ACCOMPANY THIS TAX RETURN IF LINE 8 IS $5.00 OR MORE

MAKE CHECK PAYABLE TO: CITY OF BELLEFONTAINE. WE ACCEPT MASTERCARD, VISA AND AMERICAN

EXPRESS. ...........

12. Overpayment Claimed (If Line 7 (C) exceeds Line 6) Enter Difference Here

Enter Amount of Line 12 You Want Credited to Next Year’s Tax

Or Refunded

(Only $5.00 or Over)

I CERTIFY 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 this return was prepared by a tax practicioner, check here if we may contact him/her

directly with questions regarding the preparation of this return.