Ohio Form It 1041ext - Ohio Income Tax Extension Payment Coupon For Estates And Trusts - 2012

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2012 Ohio IT 1041EXT
Federal Privacy Act Notice
Because we require you to provide us with a Social Se-
Ohio Income Tax
curity number, the Federal Privacy Act of 1974 requires
Extension Payment
us to inform you that providing us with your Social Secu-
rity number is mandatory. Ohio Revised Code sections
Coupon for Estates
5703.05, 5703.057 and 5747.08 authorize us to request
and Trusts
this information. We need your Social Security number in
order to administer this tax.
If you will be providing taxpayer information on a cartridge tape, please see “Car-
tridge Tape Ohio IT 1041ES Filing Requirements Defi nition,” which follows the
instructions for this payment coupon.
DO NOT USE PENCIL
Please cut on the dotted line.
to complete this form.
OHIO IT 1041EXT
Reset Form
Rev. 5/12
Ohio Income Tax Extension
For Taxable Year Beginning In
Extension Payment
Do NOT fold
Payment Coupon For Estates and Trusts
2012
check
or coupon.
Federal Employer Identifi cation Number
TRUST
ESTATE
Social Security Number of Decedent (estates only)
$
.
Payment
0 0
Amount
Name of trust or estate
DO NOT STAPLE, PAPER CLIP OR OTHERWISE ATTACH YOUR CHECK
Fiduciary name and title
OR CHECK STUB TO THIS COUPON. DO NOT SEND CASH. Return this
coupon with check or money order made payable to OHIO TREASURER OF
Number, street, P.O. Box, suite or room number
STATE and mail to OHIO DEPARTMENT OF TAXATION, P.O. BOX 2619,
COLUMBUS, OH 43216-2619.
City, state, ZIP code
419

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