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 18, 2023

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 2023   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                                                  Paulding          640
Clayton                 199                                                  Phillipsburg      659
Cleveland               200                                                  Pitsburg          661
Dalton                  252                                                  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                                                                   Revenue Sharing JEDD/JEDZ - complete below
Munroe Falls            533
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
Orwell                  605

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 River          New Madison               Paulding           Somerset            Revenue Sharing JEDD/JEDZ
Clayton            Highland Hills       New Miami                 Phillipsburg       South Russell       BurtonVill/Twp     982
Cleveland          Linndale             New Paris                 Pitsburg           Union               Clayton/Clay       984
Dalton             Marble Cliff         North Baltimore           Riverside          Waynesfield         Cleve/High Hills   995
                                                                                                         Cleve/Warr Hts
Elida                                                             Rock Creek         West Milton                            998
                   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
Grand Rapids       New Carlisle         Orwell                    Shreve                                 North Baltimore    988
                                                                                                         Prairie Obetz      981