CITY OF BLUE ASH - WITHHOLDING TAX RECONCILIATION
                                                  DUE ON OR BEFORE FEBRUARY 28TH
FORM W-3                           MAIL TO:       BLUE ASH TAX OFFICE                                                       (513) 745-8516
                                                  4343 COOPER ROAD                                                          Fax: (513) 745-8651
                                                  BLUE ASH, OHIO 45242-5699                                                 www.blueash.com
                                                                                                                            blueashtax@blueash.com

                                                   INSTRUCTIONS
∙ Copies of w-2's of taxable employees MUST accompany the filing of this form W-3. Include tape showing total gross wages.
∙ If non-employee compensation of $600 or more per individual was paid for work pe formedr                    in Blue Ash, copies of
  1099’s MUST also accompany this return.
∙ All blanks must be completed.

     EMPLOYER'S NAME, ADDRESS AND ACCOUNT NO.                                                ALL BLANKS MUST BE COMPLETED
                             Blue Ash Account #                               Fed ID# of Company:
                                                                              Submitted by (please print):
Name                                                                          Official Title:
Add1                                                                          Signature:
Add2                                                                          Date:
C,S,Z                                                                         Phone:
                                                                              Email:

TOTAL BLUE ASH INCOME TAX
REMITTED FOR TAX YEAR              $                                          7. First Quarter ending March 31              $

1. Total number of employees                                                  8. Second Quarter ending June 30              $

2. Total number of Blue Ash employees                                         9. Third Quarter ending September 30          $

3. Total Blue Ash Payroll for year $                                          10. Fourth Quarter ending December 31         $

4. Less payroll not subject to tax $                                          11. Credits from prior year                   $
**(Must explain below)**
5. Payroll subject to tax          $                                          12. Total remitted for the year               $
6. Withholding tax liability 
     at 1.25% of line #5           $                                          13. Overpayment credited to next year         $
                                                                              (Refunds not issued to active accounts.)
                                                                              14. Additional tax due                        $
                                                                              No taxes or credits of less than $10.00 shall be collected or refunded
              EXPLANATION OF PAYROLL NOT SUBJECT TO TAX / W-2s NOT FULLY SUBJECT TO BLUE ASH TAX
                                   **(If no explanation is provided, 1.25% of total gross payroll is due and payable.)**

                                                  FOR OFFICE USE ONLY

                                                  (Blue Ash suggests that you retain a copy of this return for your records)
01-2016