ON NEXT 
(513) 745-8516  TAX YEAR 
PAYMENT DUE 
Income Tax Office 
Fax: (513) 745-8651 

blueashtax@blueash.com 

YEAR 

DECLARATION FOR NEXT TAX _____________________ _____________________ 

TAX YEAR  
 
 PAYMENT AMOUNT ENCLOSED: ______________ PAYMENT DUE ON EXTENDED                   _____________________________________________
Preparer’s Phone #: Preparer’s Fax #: 

  NO SUCH ACCOUNT NAME OR NUMBER ESTABLISHED        OTHER 
□ □
 
ADDRESS 

FOR TAX OFFICE USE ONLY
 
EXTENSION REQUEST FORM 
        
 TAXPAYER NAME 

________________________________

Name: Address: ______________________________

F.I.D.# or  
   EXTENSION REQUEST GRANTED TO: ___________________               EXTENSION REQUEST GRANTED BY: ___________________            
City of Blue Ash 4343 Cooper Road Blue Ash, Ohio 45242-5699 www.blueash.com DATE OF REQUEST: ___________________ FOR TAX YEAR: _______________________ EXTENSION REQUESTED TO (DATE): ____________________ BLUE ASH TAX ACCT. NUMBER              □ □
   Type or print taxpayer(s) FID number or Blue Ash Tax Account Number, name, address and how payment should be applied below.   Please be sure to include 2 copies and a self-addressed stamped envelope to ensure return of your request.       TAX PREPARER’S INFORMATION (please print):  Preparer’s Preparer’s Preparer’s City, State, Zip Code: ____________________________________  Revised (01/2010)