Return with attachments 
2022LF                                                         due by April 18, 2023

                               Part 1 - Account Information
Account

Social Security Number                                   Spouse
Name
Resident 
Address

Mailing 
Address
Phone                                       Email
Date moved into city                        Date moved out of city

                                            Filing Status
                     Single                                    Married filing separately
                     Married filing jointly                    Head of Household

         Part 2 - Taxable Income  & Tax Calculation - Round to Whole Dollars

                                    A - W-2 Income
1        Enter wages from W-2s
2        Adjustments from Worksheet A
3        Intentionally Left Blank

         Taxable wages                                         4
                     If you have no other income to report, skip to Box 15

                                 B - Miscellaneous Income
5        Gambling/lottery winnings
6        Other - please explain

         Total miscellaneous income                            7
                     If you have no other income to report, skip to Box 15

                                 C - Income from Schedules
8        Schedule C
9        Schedule E 
10       Partnership/S-Corp Income
11       Ordinary Gains
12       1099 - Misc
13       Enter 50% of Loss

         Total of schedules (add 8 - 13) if loss enter 0       14

Newark Taxable Income                                          15

Newark Tax                                                     16

                                  Continue on back

                           Part 3 - Credit Calculation

Newark Tax                                                   17
                           A - Withheld Tax/Other Credits

18        Newark tax withheld on W-2s
19        Other city credit
20        Partnership/S-Corp tax payments

          Total credits (add 18 - 20)                        21

Newark Tax after credits                                     22

If Box 22 is $200 or more, see instructions for important information regarding your 2022 tax.  You 
            may be required to file a 2023 Estimated Tax Return.

                           B - Estimated Tax Payments

23        Estimated 2022 tax payments
24        Taxes carried forward from a prior year

          Total estimated tax payments                       25

                     Part 4 - Payment/Overpayment Information

2022 Tax Payment Due                                         26
                         If Box 26 is less than $10.01 - no payment due

            Make checks payable to:  Newark City Income Tax

2022 Overpayment (indicate how to apply below)               27
                     If Box 27 is less than $10.01 - no credit or refund

          Credit Account                                     Refund 

   I hereby declare that the information stated above is true under penalty of perjury.

Signature                  Date                    Signature                Date

                                                             May we contact this preparer?
Signature of Preparer (if different from taxpayer) Date                 Yes            No

Mail to:                                                     Questions?
                                                             740-670-7580  phone
Newark City Tax Office                                       740-670-7581  fax
PO Box 4577                                                  citytax@newarkohio.net
Newark, OH  43058-4577

              Worksheet A - Wage Adjustment
See Worksheet A Instructions for assistance with this form.  If you need to complete 
this form, we strongly encourage you to call for an appointment or come into our office 
               so our staff may assist you.

          Part 1 - Moved in or out of Newark in 2021

    A     B    C         D  E                             F    G
                                                            # Mo 
    Box b W-2  Newark       # Mo                            Lived out 
W-2                   A - B                           C  ÷ D          E  ×F
    EIN   Wage Wage         Worked                          of 
                                                            Newark
1
2
3
4
5
          Total Adjustment - Enter on line 2 on your tax return.

               Part 2 - You turned 18 in 2021

    A     B    C         D  E

    Box b W-2  # Mo         # Mo 
W-2                   A  ÷ B                          C  ×D
    EIN   Wage Worked       Under 18

1
2
3
4
5
Total Adjustment - Enter on line 2 of your tax return.

When used, this worksheet is part of your return, please remit a copy with your return.

            Worksheet B - Other City Loss Calculation

            Step 1 - Loss Adjustment

            A B                     C
            Loss 
                                                  Allowable 
  City Name Reported on 
                                                  Loss
            Sch E
                                    0.5714
                                    0.5714
                                    0.5714
                                    0.5714
                                    0.5714
  Allowable other city loss - enter in Box D below

            Step 2 - Schedule E Income
                                                            Gain/Loss
A Net gain or loss from income/rentals in Newark
B Net gain or loss from income/rentals outside any city
C Net gain from income/rentals in other city
D Net allowable city loss from above
E Enter this amount on Line 8 on Return

When used, this worksheet is part of your return, please remit a copy with your return.

  Worksheet C - Other City Credit

  Section 1 - Other City Tax Return Credit

If Box 14 of your return is a loss or less than the income taxed on the other city return, do not complete 
  this section.  Please contact our office for assistance.

  Name of city                                  Tax paid   Income taxed
1
2
3
4
5
  Total income taxed by other city
                                                Multiply   x 0.01

A Credit for filing with other cities

When used, this worksheet is part of your return, please remit a copy with your return.

The following are required to be attached to your return
Copies of W-2s showing other city taxes withheld
Any listing of other city taxes withheld from your employer