Form Kwh 4 - Self-Assessing Purchaser Tax Return

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KWH 4
Rev. 7/13
Reset Form
P.O. Box 530
Columbus, OH 43216-0530
Phone (614) 466-7026 • Fax (614) 728-1806
Self-Assessing Purchaser Tax Return
Account number
Period
Name
Address
Street address
City
State
ZIP code
Column B
Column C
Column A
1. Number of taxable KWHs received
2. Line 1 multiplied by $0.00075
$
.00
3. Price of all KWHs
$
.00
4. Line 3 multiplied by 0.035
$
.00
0
5. Tax due (total of lines 2 plus 4)
$
.00
6. Interest (see instructions)
$
.00
7. Total amount due (total of lines 5 plus 6)
$
0
.00
By the 20th day of each month, the return and schedule shall be fi led with the Department of Taxation along with payment
of the total amount due for the preceding month. Make checks payable to Ohio Treasurer of State and write the account
number on your check. Failure to timely fi le and pay the tax may result in an additional charge up to $50 or 10% of the tax
due, whichever is greater.
I declare under penalties of perjury that this return, including any accompanying schedules and statements, has been examined
by me and to the best of my knowledge and belief is a true, correct and complete return and report.
Signature
Title
Telephone
Date
Internal Use Only

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