Form R-I - Individual Income Tax Return - 2012 Page 2
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2SECTION D
RETIRED AND TAXPAYERS WITH NO TAXABLE INCOME CHECK APPROPRIATE EXPLANATION(S)
Retired with No Taxable Income
All Tax Withheld @ 2.25% By My Employer
Lived and Worked Outside Of Dayton
Active Duty Military
Business or Rental Sold on
to
or Closed on
I certify that I had NO Schedules E, C, K1, 2106, 4797, or 1099-MISC. income or losses reported on my Federal Tax Return.
SECTION A
TOTAL W-2 WAGES
Employer’s Name
Work Address
Dayton tax
Other City Tax
Total Taxable Wages*
Total Taxable Wages*
*Total Taxable Wages: Box 5 is usually, but not always, the highest gross wage. Use the largest amount from boxes
1, 3, 5, or 18, of your W-2 tax forms. Please provide a written explanation if Box 5 is not the highest wage figure.
SECTION E
OTHER INCOME OR LOSS AND FORM 2106 EXPENSE
List all income as reported to the IRS on each of the following attached Schedules or Forms. Copies of the Federal Income Tax Return and/or various
applicable Federal Schedules are required to be included with your tax return.
Profit and/or Loss
Profit and/or Loss
Profit and/or Loss
Schedule C
Form 4797
Schedule K-1
Schedule C
Form 1099-MISC
Schedule K-1
Schedule E
Form 1099-MISC
Other
Schedule E
Form 1099-MISC
Other
Total to Line 2
Total to Line 2
Total to Line 2
Please note losses are not deductible against W-2 wages.
Form 2106 Expenses:
Total to Line 2. Form 2106 expenses are deductible from wages, subject to 2% of adjusted gross
income. IRS Schedule A is required to be attached to this return for supporting documentation.
SCHEDULE Y
ALLOCATION OF PROFITS
a. Located
b. Located in
c. Percentage
Everywhere
Dayton
(b ÷ a)
1.
Original Cost of Real and Tangible Personal Property ..............................
%
Gross Annual Rentals Paid Multiplied by 8 ...............................................
%
Total Step 1 ...............................................................................................
%
2.
Gross Receipts from Sales Made and/or Work or Services Performed ........
%
3.
Wages, Salaries and Other Compensation Paid ......................................
%
4.
Total Percentages ......................................................................................
%
5.
Average Percentage (Total Percentages/Number of Percentages Used) ......................................................................................
%
Additional addresses or comments:
IMPORTANT INFORMATION: MAIL RETURN WITH:
PAYMENT DUE TO: City of Dayton, Division of Revenue and Taxation, PO Box 643700, Cincinnati, OH 45264-3700
NON-PAYMENT OR ZERO BALANCE DUE TO: City of Dayton, Division of Revenue and Taxation, PO Box 7999, Akron, OH 44306-0999
REFUND REQUEST TO: City of Dayton, Division of Revenue and Taxation, PO Box 7999, Akron, OH 44306-0999
Completed tax returns will be accepted through the Fax as an original document. All necessary information and attachments must be included. Income tax
preparation service will be provided only to those households earning $35,000 or less. In the event your check is returned unpaid for insufficient funds or
uncollected funds, we may electronically debit your account for the principal amount of the check. A return check fee, currently $25.00, as set forth by the
Director of Finance, will be assessed.
Online tax preparation tool: Forms are available at
Forms line 937-333-3501, Fax Number 937-333-4280, E-mail for forms: taxforms@daytonohio.gov
Forms Available: Office Hours: Monday through Friday 8:00 AM to 5:00 PM City Hall, First Floor Lobby, 101 W Third St. Dayton, Oh 45402
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