Form R - Xenia City Income Tax - 2004
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2004 - XENIA CITY INCOME TAX - 2004
DIVISION OF TAXATION
Form R
Form R
101 N. Detroit St.
P O Box 490
Fiscal Year Begin___/___/2004 End___/___/2005
*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 15, 2005
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 2004, PLEASE CHECK
REASON BELOW:
Taxpayer
Spouse
Unemployed (Entire year).....................
____
____
Retired..(No Schedule E)................................................
____
____
Social Security Disability.......................
____
____
You must obtain a Xenia extention if a Federal extention has been granted. This
ADC/General Relief................................
____
____
Extention must be requested prior to the due date of the return.
Other (explain)____________...............
____
____
WAGES*
EMPLOYER
XENIA TAX W/H
OTHER CITY TAX W/H
GROSS WAGE AMT.
TAX OFFICE USE ONLY
Do not use this space
*Please complete this section-one line for each W-2*
Not to exceed 1.5% (See Pg 4)
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 2)...........................................................................
Do NOT subtract business losses (Line 2) from wage income (Line 1C or Line 1E)
.... 3___________________
_______________________
3. ADJUSTMENT FROM SCHEDULE X (Page 2).........................................................................................................
.... 4___________________
_______________________
4. TOTAL INCOME (Line 1 + Line 2 or Line 2 +/- Line 3)............................................................................................
.... 5___________________
_______________________
5. AMOUNT ALLOCABLE TO XENIA (if Schedule Y –Page 2- is used _____%..........................................................
6*
TOTAL TAXABLE INCOME (Line 1C, 1E, 4 or 5)............................................................................................................
....*6__________________
_______________________
7*
TOTAL TAX DUE (1.75% of Line 6)..........................................................................................................................
....*7__________________
________________________
TAX CREDITS
W-2
8*
CREDITS:
A
(A) Xenia tax withheld (From Line 1A)..............................................................
(A)_________________
C
(B)_________________
(B) Estimate......................................................................................................
E
(C)_________________
(C) Tax paid to other cities (From Line 1B)..............................................................
F
K(1)
Do not include amounts refunded to you!
1040
(D) TOTAL CREDITS......................................................................................
....................................
*8(D)__________________
________________________
1065
9*
TAX DUE – Net (Line 7 less Line 8-D).................................................................................................
....*9__________________
________________________
1099
10. Penalty $__________Interest (After April 15, 2005) $____________...............................
....10__________________
________________________
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”) and 1040
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 April 15, 2005 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
_____________________________________________________________________________________________________________________________ ____________
Signature of Spouse
Date
Address
Phone No.
Pre-Audited by______________Date___________________Audited by________________Date____________File ___________________________________
IT 2004 REV 9/04
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