Form R - Income Tax Return
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1
2
3
4Form R
FILE WITH
MAKE CHECK OR MONEY ORDER
INCOME TAX RETURN
PAYABLE TO
FILING REQUIRED EVEN IF NO TAX DUE
FOR THE CALENDAR YEAR
OR FISCAL PERIOD
TO
ON OR BEFORE
ACCOUNT #
NAME OF EMPLOYER
ADDRESS: Street
TAXPAYER'S NAME AND ADDRESS
City
TELEPHONE:
Home
Business
FEDERAL ID#
TAXPAYER SS#
WERE YOU A RESIDENT AT
SPOUSE SS#
YES
NO
ANY TIME DURING 20__?
DID YOU
YES
NO
IF MOVED SINCE THE PREVIOUS FINAL RETURN WAS DUE
FILE A PREVIOUS YEAR RETURN?
HAS IRS
GIVE DATE:
YES
NO
INCREASED YOUR INCOME TAX LIABILITY FOR ANY PRIOR YEAR
IF SO, HAS
YES
NO
INTO CITY
OR OUT OF
AN AMENDED CITY INCOME TAX RETURN BEEN FILED
PRINCIPAL BUSINESS ACTIVITY:
TYPE OF BUSINESS:
CORP
PARTN
SOLE PROP
IF OTHER EXPLAIN:
NOTE: Page 2 must be completed if you have taxable rental property or business income.
1. WAGES, SALARIES, TIPS AND OTHER EMPLOYEE COMPENSATION (ATTACH ALL W-2'S) . . . . . . . . . . $
2. OTHER TAXABLE INCOME OR DEDUCTIONS FROM PAGE 2 . . . . . . . . . . . . . . . . . . . . . .
$
3. TAXABLE INCOME: LINE 1 PLUS LINE 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
4. MUNICIPAL TAX
OF LINE 3 . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
5. CREDITS:
A. TAX WITHHELD BY EMPLOYER . . . . . . . . . . . . . . . . . . .
.
$
B. ESTIMATED TAX PAID . . . . . . . . . . . . . . . . . . . . . . .
.
$
C. CREDIT FOR TAXES PAID TO OTHER CITIES . . . . . . . . . . . . . .
.
$
D. PRIOR YEAR OVERPAYMENTS . . . . . . . . . . . . . . . . . . . . .
$
E. OTHER CREDITS . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
F. TOTAL CREDITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
6. TAX DUE (IF LINE 4 IS GREATER THAN LINE 5F, PAYMENT OF BALANCE MUST ACCOMPANY THIS RETURN) .
$
7. PENALTY . . . . . . . .
$
PLUS INTEREST . . . . .
$
$
8. AMOUNT DUE BEFORE ESTIMATED TAXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
9.
$
$
OVERPAYMENT: REFUNDED .
OR CREDITED TO EST. TAXES .
DECLARATION OF ESTIMATED TAX FOR YEAR 20__
10.
$
$
INCOME SUBJECT TO TAX . . .
TIMES TAX RATE OF
FOR GROSS TAX OF
11. LESS EXPECTED TAX CREDITS.
A.
$
TAX WITHHELD BY EMPLOYER . . . . . . . . . . . . . . . . . . . . . . . .
B.
$
PAYMENTS ON TAXABLE INCOME TO ANOTHER MUNICIPALITY . . . . . . . . . .
C.
$
TOTAL CREDITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12. NET TAX DUE (LINE 10 LESS LINE 11C) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
A. OVERPAYMENT FROM PRIOR YEAR(S) . . . . . . . . . . . . . . . .
$
13. AMOUNT PAID WITH THIS DECLARATION (1/4 LINE 12. LESS LINE 12A.) . . . . . . . . . . . . . . . . .
$
14. BALANCE OF ESTIMATED TAX . . . . . . . . . . . . . . . . . . . . . . .
$
TOTAL
$
(LINE 8) +
$
(LINE 13) =
AMOUNT DUE
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 & COMPLETE, IF PREPARED BY PERSON OTHER THAN TAXPAYER, THE DECLARATION IS BASED ON ALL INFORMATION OF WHICH PREPARER HAS ANY KNOWLEDGE.
Signature of Preparer
Date
Signature of Taxpayer
Date
Signature of Taxpayer
Date
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Parent category: Financial