CCA – DIVISION OF TAXATION
                   CLEVELAND OH 44113-1503                                       Municipal Income Tax Forms
                   (216) 664-2070    (800) 223-6317
                   www.ccatax.ci.cleveland.oh.us

                                                                                              Net Profit Estimate
                                                                                                      Due April 15, 2024

Name of Business                                                             Federal Identification Number

Address                                                                      Trade Name

Address                                                                      Local Business Address

City, State, Zip                                                             Principal Business Activity Code   

Estimate for Calendar Year End 2024   OR   Fiscal Year End Beginning                                                             Ending
        1               2        3       4               5       6                             2          3          4            5       6
      MUNICIPALITY      CODE ESTIMATED  PRIOR YEAR       BALANCE PAYMENT DUE         1                ESTIMATED      PRIOR YEAR  BALANCE  PAYMENT DUE
                             ANNUAL TAX  CREDIT        ESTIMATED ¼ OF COL. 3     MUNICIPALITY  CODE   ANNUAL TAX     CREDIT     ESTIMATED ¼ OF COL. 3
                                                         TAX DUE LESS COL. 4                                                     TAX DUE  LESS COL. 4
Burton                  176                                                  Orwell            605
Clayton                 199                                                  Paulding          640
Cleveland               200                                                  Phillipsburg      659
Dalton                  252                                                  Pitsburg          661
Edon                    275                                                  Riverside         680
Elida                   276                                                  Rock Creek        698
Geneva-on-the-Lake      347                                                  Russells Point    703
Germantown              348                                                  Seville           722
Grand Rapids            356                                                  Shreve            755
Grand River             357                                                  Somerset          762
Highland Hills          371                                                  South Russell     772
Linndale                420                                                  Union             797
Marble Cliff            459                                                  Waynesfield       833
Mentor-on-the-Lake      495                                                  West Milton       835
Montpelier              517
Munroe Falls            533                                                  Revenue Sharing JEDD/JEDZ - complete below
New Carlisle            534
New Madison             538
New Miami               539
New Paris               541
North Baltimore         548
North Randall           560
Oakwood (Paulding Cnty) 585
Obetz                   587                                                  TOTALS

I have examined this declaration and to the best of my knowledge, it is correct. Do you authorize your preparer to contact us regarding this return?
                                                                                 YES        NO 
                                                                                      @       @
Signature of Officer or Partner                                    (Date)        Signature of Person or Firm Preparing the Form                   (Date)

Title                                                                            Address of Preparer                 
                                                   KEEP A COPY FOR YOUR RECORDS         
                        NO Payment Enclosed - Mail to:           Payment Enclosed - Mail to:                    Refund Request - Mail to: 
      MAIL              CCA – Division of Taxation               CCA – Division of Taxation                     CCA – Division of Taxation
      TO                PO BOX 94810                             PO BOX 94723                                   PO BOX 94520
                        Cleveland OH 44101-4810                  Cleveland OH 44101-4723                        Cleveland OH 44101-4520

INSTRUCTIONS – FORM CCA-201ES                                   Column 4 – Enter prior year credit

Column 1 – Names the municipality                               Column 5 – Balance Estimated Tax Due

Column 2 – Assigns a code number for that municipality          Column 6 – Payment Due. The tax paid with this declaration must
                                                                               be at least ¼ of estimated tax. Overpayment from prior  
Column 3 – Estimated annual tax due by municipality. Multiply Net              year may be deducted from the first quarter. If report  
          Profit by tax rate for municipality of employment.                   covers more than one municipality, the tax paid with the  
          See tax rate schedule                                                return must be allocated to these municipalities

                                DUE DATE FOR FISCAL YEAR END RETURNS

           Taxpayers reporting on a fiscal year basis shall file a declaration on or before the
            fifteenth day of the fourth month after the beginning of each fiscal year or period.

                                  ANNUAL
           MONTH OF               RETURN/              ESTIMATE
                                  ST                         ND                     RD                TH 
           YEAR END               1 QTR.                     2  QTR.              3     QTR.          4 QTR.

          December                April                June                       September           December
          January                 May                  July                       October             January
          February                June                 August                     November            February
          March                   July                 September                  December            March
          April                   August               October                    January             April
          May                     September            November                   February            May
          June                    October              December                   March               June
          July                    November             January                    April               July
          August                  December             February                   May                 August
          September               January              March                      June                September
          October                 February             April                      July                October
          November                March                May                        August              November

                                        CCA MEMBER MUNICIPALITIES
Burton             Grand Rapids         New Carlisle                 Orwell             Shreve             Revenue Sharing JEDD/JEDZ
Clayton            Grand River          New Madison                  Paulding           Somerset           Burton Vill/Twp     982
Cleveland          Highland Hills       New Miami                    Phillipsburg       South Russell      Clayton/Clay        984
Dalton             Linndale             New Paris                    Pitsburg           Union              Cleve/High Hills    995
                                                                                                           Cleve/Warr Hts      998
Edon               Marble Cliff         North Baltimore              Riverside          Waynesfield
                                                                                                           Gateway
Elida                                                                Rock Creek         West Milton                            990
                   Mentor-on-the-Lake   North Randall                                                      High Hills/Cleve    996
Geneva-on-the-Lake Montpelier           Oakwood (Paulding Cnty)      Russells Point                        Emerald Park        993
Germantown         Munroe Falls         Obetz                        Seville                               IX Center           992
                                                                                                           North Baltimore     988
                                                                                                           Prairie Obetz       981
                                                                                                           Shaker Square       994