Form R - Xenia City Income Tax - 2003

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2003 - XENIA CITY INCOME TAX - 2003
DIVISION OF TAXATION
Form R
Form R
101 N. Detroit St.
P O Box 490
Fiscal Year Begin___/___/2003 End___/___/2004
*If ALL your taxable earnings are reported on
Xenia, OH 45385-0490
W-2 forms, only the Lines marked with an
(937) 376-7248
DUE ON OR BEFORE APRIL 30, 2004
asterisk (*) need be completed.
FAX (937) 376-8914
LATE FILING OF THIS RETURN SUBJECTS YOU
WEB:
TO INTEREST AND A MINIMUM $25.00 PENALTY
WILL THIS BE YOUR FINAL RETURN FOR THE CITY OF XENIA?______
RESIDENCY STATUS – Check one
MARITAL STATUS – Check One
____Resident
____Single
TAXPAYERS SSN, NAME(S) & CURRENT ADDRESS
____Non-resident
____Married
(___) Filing Separately
____Partial year resident
____Separated
From___________To_____________
Social Sec. No.______-_____-_______
Spouse______-_____-_______
Fed. ID No.(Businesses)____________
________________
IF YOU HAD NO TAXABLE INCOME
FOR 2003, PLEASE CHECK
REASON BELOW:
Taxpayer
Spouse (W)
Unemployed (Entire year).....................
____
____
Retired..(No Schedule
____
____
E)................................................
____
____
You must obtain a Xenia extention if a Federal extention has been granted. This
Social Security Disability.......................
____
____
Extention must be requested prior to the due date of the return.
ADC/General Relief...............................
____
____
Other (explain)____________...............
GROSS WAGE AMT.
TAX OFFICE USE ONLY
WAGES
EMPLOYER
XENIA TAX W/H
OTHER CITY TAX W/H
Do not use this space
*Please complete this section-one line for each W-2*
Not to exceed 1.5% (See Pg 2)
Attach
all
W-2’s
Here
1*
TOTAL WAGES AND WITHHOLDING
1A
1B
1C*
LESS EMPLOYEE BUSINESS EXPENSES. Copies of Federal return (1040), Schedule A and… 1D
(______________)
(__________________)
2106 must be attached.
Work sheets will not be accepted.
TOTAL WAGES (1C less 1D)................*1E ______________
___________________
OTHER INCOME
.... 2__________________
_____________________
2. INCOME OTHER THAN WAGES FROM SCHEDULE W (Page 4)..........................................................
Do NOT subtract business losses (Line 2) from wage income (Line 1C)
.... 3__________________
_____________________
3. ADJUSTMENT FROM SCHEDULE X (Page 4).........................................................................................
.... 4__________________
_____________________
4. TOTAL INCOME (Line 1 + Line 2 or Line 2 +/- Line 3)...............................................................................
.... 5__________________
_____________________
5. AMOUNT ALLOCABLE TO XENIA (if Schedule Y –Page 4- is used _____%...........................................
6*
TOTAL TAXABLE INCOME (Line 1E, 4 or 5)..............................................................................................
....*6__________________
______________________
....*7__________________
______________________
7*
TOTAL TAX DUE (1.75% of Line 6)............................................................................................................
TAX CREDITS
W-2
8*
CREDITS:
A
(A)______________
____________________
(A) Xenia tax withheld (From Line 1A)................................................
C
(B) Estimate........................................................................................
(B)______________
____________________
E
(C)______________
____________________
(C) Tax paid to other cities (From Line 1B)........................................
F
K(1)
Do not include amounts refunded to you!
1040
................................
*
8(D)________________
____________________
(D) TOTAL CREDITS.........................................................................
1065
....*9________________
____________________
9*
TAX DUE – Net (Line 7 less Line 8-D)..............................................................................
1099
....10________________
____________________
10. Penalty $__________Interest (After May 1, 2004) $____________................................
1120(S)
...*11________________
____________________
2106
11*
TOTAL AMOUNT DUE (Make check payable to the City of Xenia)................................
4797
Amount less than $2.00 need not be paid. (Return must be filed.)
8825
Misc.
12. OVERPAYMENT (Line 8-D less Line 7)......$____________
Credit to next year’s tax.............................……$____________ Refund $__________
Amt. Rec’d
Overpayments less than $2.00 will not be refunded or credited.
Cash
Check
M/O
Visa/MC
IMPORTANT:
All Federal Schedules (including “Statements”, if any)
be attached. Returns received without
complete Schedules will be marked
MUST
ALL
"INCOMPLETE" and returned to the taxpayer, along with any remittance enclosed with the return.
A
"
"
N
INCOMPLETE
RETURN IS NOT A FILED
!
Completed returns must be received by May 1, 2004 to avoid penalty and interest charges.
RETURN AND CAN CAUSE LATE PENALTY CHARGES
The undersigned declares that this return (and accompanying schedules) is a true, correct and complete return for the taxable period stated. Tax preparer is
authorized to disclose information concerning this tax return to the Xenia tax office.
_____________________________________________________________________
Signature of Taxpayer or Agent
Title
Date
Signature of person preparing return or keeping books
Date
_________________________________________________________________________________________________________________________________________
_ S ignature of Spouse
Date
Address
Phone No.
Pre-Audited by_____________________Date____________Audited by________________Date____________File
Date___________________________________
IT 2003 REV
9/02

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