City of Fairfield                                                                         
 
                  APPLICATION FOR EXTENSION REQUEST 
                            (Due on or before the Original Due Date of Return) 
                                                         
______________________      ______________________                ____________________
Original Due Date of Return Extension Date Requested              Previous Extension Date 
 
The undersigned taxpayer, or duly authorized agent for the taxpayer, hereby requests an 
extension of time as indicated below within which to file an annual Fairfield Income Tax return, 
form IR (Individual) or BR (Business), for the taxpayer account and number shown below.  The 
reason for this request is: (Note: 1 or 2 must be completed) 
 
1.  _____ An extension has been requested of the IRS for filing the federal income tax  
          return and the Fairfield extension would not be more than six (6) months beyond 
          the original due date of return. 
           
2.  _____ Other (explain): ___________________________________________________ 
 
NOTE: A copy of the Federal extension              _________________________     ___________
    must accompany extension or                    Signature of Requistioner     Date 
    final return.
 
NAME OF TAXPAYER(S) EXTENSION REQUESTED FOR: (All accounts are by SS# or FID#) 
 
Taxpayer(s)                 Address                               SS# or FID # (Required)         
 
Reason(s) for Disapproval:                                       _____ Disapproved 
                                                                 _____ Approved 
_____  Request received after due date for filing.                
                                                                  
_____  Social Security Number or Federal Identification           
    Number not included.                                          
                                                                  
_____  Taxpayer’s account is delinquent from prior years.         
                                                                  
                                                          th
NOTE: An extension does not waive the tax due by April 15   ,     
an estimated liability amount must be paid-in at the time of the  
extension request.  Failure to do so will require our office to   
                                                                  
assess interest as required under Section 181.10 of the 
Fairfield Earned Income Tax Ordinance.                            
 
                                       INCOME TAX DIVISION 
          701 Wessel Drive, Fairfield, Ohio 45014   513-867-5327  (TDD-867-5392)