Form Ir - Individual Blue Ash Earnings Tax Return - 2004
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1
2Form IR
File With
INDIVIDUAL
Tax Office Phone: (513) 745-8516
BLUE ASH
Fax # (513) 745-8651
2004 — BLUE ASH EARNINGS TAX RETURN — 2004
INCOME TAX DIVISION
DUE ON OR BEFORE APRIL 15, 2005.
FEDERAL EXTENSION MUST
4343 Cooper Road
ACCOMPANY BLUE ASH
Blue Ash, Ohio 45242-5699
EXTENSION REQUEST
LATE FILING OF THIS RETURN SUBJECTS YOU TO INTEREST AND A MINIMUM PENALTY OF $25.00.
TAXPAYER’S NAME, ADDRESS
ACCOUNT NO.
CURRENT EMPLOYER ___________________________________________
ADDRESS _____________________________________________________
_____________________________________________________________
SS# TAXPAYER _________________ SS# SPOUSE ________________
PHONE # HOME (
)______________ WORK (
)___________________
IF MOVED SINCE THE PREVIOUS FINAL RETURN WAS DUE GIVE DATE OF MOVE
INTO BLUE ASH _______________ OUT OF BLUE ASH _______________
1.
QUALIFYING WAGES (ATTACH ALL W-2’s)............................................................................................................ ............................... $ ____________
2.
OTHER TAXABLE INCOME AND/OR DEDUCTIONS FROM LINE 20, PAGE 2 - SEE INSTRUCTIONS .................. ............................... $ ____________
Note: Page 2 must be completed if you have taxable renta l property or business income.
(INTEREST, DIVIDEND, CAPITAL GAINS, UNEMPLOYMENT, AND RETIREMENT INCOME NOT TAXABLE)
3.
TAXABLE INCOME: LINE 1 PLUS OR MINUS LINE 2 ........................................................................................... ............................... $ ____________
4.
BLUE ASH TAX: 1% OF LINE 3............................................................................................................................. ............................... $ ____________
5.
CREDITS
a.
TAX WITHHELD BY EMPLOYER FOR BLUE ASH ......................................................................................... $ ____________
b.
2004 ESTIMATED TAX PAID TO BLUE ASH................................................................................................. $ ____________
c.
2004 TAX PAID CITY OR VILLAGE OF ___________________________................................................... $ ____________
(NOT TO EXCEED 1% OF THAT PORTION TAXED PER W-2 - SEE INSTRUCTIONS - RESIDENTS ONLY)
d.
PRIOR YEAR OVERP AYMENTS.................................................................................................................... $ ____________
e.
TOTAL CREDITS ........................................................................................................................................... ............................... $ ____________
6.
IF LINE 4 IS GREATER THAN LINE 5e PAYMENT OF BALANCE MUST ACCOMPANY THIS RETURN ................2004 TAX DUE ........ $ _________
7.
OVERPAYMENT TO BE REFUNDED $ _______________ OR CREDITED $ _______________ TO NEXT YEAR’S ESTIMATE
(If Line 5e is greater than Line 4)
No taxes or refunds of less than $1.00 shall be collected or refunded.
By Law, all Refunds & Credits in excess of $10.00 are being reported to I.R.S.
DECLARATION OF ESTIMATED TAX FOR YEAR 2005
(MANDATORY IF ESTIMATED LIABILITY IS $100.00 OR MORE)
8.
TOTAL INCOME SUBJECT TO TAX $ _______________ MULTIPLY BY TAX RATE OF 1% FOR GROSS TAX OF ........................... $ _____________
9.
LESS EXPECTED TAX CREDIT
a.
WITHHELD BY EMPLOYER FOR BLUE ASH (NOT TO EXCEED 1% OF THAT PORTION TAXED)............... $ ____________
b.
PAYMENTS TO ANOTHER MUNICIPALITY (NOT TO EXCEED 1% OF THAT PORTION TAXED) ................ $ ____________
c.
TOTAL CREDITS ........................................................................................................................................... $ ____________
10. NET TAX DUE FOR 2005 (LINE 8 LESS LINE 9c ................................................................................................... ............................... $ _____________
a.
OVERPAYMENT FROM PRIOR YEAR (FROM LINE 7 ABOVE)...................................................................... $ ____________
11. AMOUNT PAID WITH THIS DECLARATION (NOT LESS THAN ¼ OF LINE 10, LESS LINE 10a)
$ _________
12. TOTAL OF THIS PAYMENT (LINE 6 PLUS LINE 11)
$ _________
MAKE CHECKS PAYABLE TO BLUE ASH INCOME TAX DIVISION........................................................................ ...............................
FOR TAX OFFICE USE ONLY
Tax $ ____________
Penalty $ _____________
Interest $ _______________
Late ___________ Months
TOTAL DUE (Tax & Assessments) ....................................................................$ ____________
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 IS
BASED ON ALL INFORMATION OF WHICH PREPARER HAS ANY KNOWLEDGE.
May we
________________________________________________________
____________________________________________________
discuss this
Signature of Person Preparing if Other Than T axpayer
Date
Signature of Taxpayer
Date
return with the
preparer shown
to the left?
________________________________________________________
____________________________________________________
?
?
Address
Telephone Number
Yes
No
Signature of Taxpayer
Date
(BLUE ASH SUGGESTS THAT YOU MAKE A PHOTOCOPY OF BOTH SIDES OF THIS RETURN AND RETAIN FOR YOUR RECORDS)
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