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Depa~ment of 2016 Ohio IT 1040
* Ohio I Taxation
Rev. 9/16 1111111111 1111111 1111111 *
Individual Income Tax Return 16000106
Note: This form encompasses the IT 1040, IT 1040EZ and amended IT 1040X.

Is this an amended return? Yes No If yes, include Ohio IT RE (do not include a copy of the previously ﬁled return)
Is this a Net Operating Loss (NOL) carryback? Yes No If yes, include Schedule IT NOL
Taxpayer's SSN (required)  If deceased Spouse’s SSN (if ﬁling jointly)  If deceased Enter school district # for
this return (see instructions).
check box check box SD# 
First name M.I. Last name

Spouse's ﬁ rst name (only if married ﬁling jointly) M.I. Last name

Mailing address (for faster processing, use a street address)

City State ZIP code Ohio county (ﬁ rst four letters)

Home address (if different from mailing address) – do NOT include city or state ZIP code Ohio county (ﬁ rst four letters)

Foreign country (if the mailing address is outside the U.S.) Foreign postal code

Ohio Residency Status – Check applicable box Filing Status – Check one (as reported on federal income tax return,
Full-year Part-year Nonresident with limited exceptions – see instructions)
resident resident Indicate state
Single, head of household or qualifying widow(er)
Check applicable box for spouse (only if married ﬁling jointly)
Full-year Part-year Nonresident Married ﬁling jointly Married ﬁling separately
Yes No
resident resident Indicate state 
Yes No Did you ﬁ le the federal extension 4868? ......................................
Ohio Political Party Fund Yes No
Do you want $1 to go to this fund?............................................ Is someone else claiming you or your spouse (if joint return) as
a dependent? If yes, enter "0" on line 4........................................
If joint return, does your spouse want $1 to go to this fund?.....
Note: Checking “Yes” will not increase your tax or decrease your refund.
1. Federal adjusted gross income (from the federal 1040, line 37; 1040A, line 21; 1040EZ,
line 4; 1040NR, line 36; or 1040NR-EZ, line 10). Place a negative sign (“-“) before the ﬁgure if
the amount is less than -0-...................................................................................................................1. . 00
00
2a.Additions to federal adjusted gross income (include Ohio Schedule A, line 10) ............................2a. .

2b.Deductions from federal adjusted gross income (include Ohio Schedule A, line 35).....................2b. . 00
3. Ohio adjusted gross income (line 1 plus line 2a minus line 2b). Place a negative sign (“-“)
before the ﬁgure if the amount is less than -0-................................................................................. 3. .00
00
4. Personal and dependent exemption deduction (if claiming dependent(s), include Schedule J)......4. .

5. Ohio income tax base (line 3 minus line 4; if less than -0-, enter -0-)..............................................5. . 00

6.Taxable business income (include Ohio Schedule IT BUS, line 13) ................................................ 6. .00
7.Line 5 minus line 6 (if less than -0-, enter -0-).................................................................................. 7. .00
Include your federal income tax return
if line 1 of this return is -0- or negative.

Do not write in this area; for department use only. / /
Postmark date Code

2016 IT 1040 – page 1 of 2

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                        Depa~ment of                          2016 Ohio IT 1040 
*      Ohio I Taxation 
                        Rev. 9/16                Individual Income Tax Return                                                                                         1111111111 11111111111111     *  
                                                                                                                                                                              16000206
  SSN 
  7a. Amount from line 7 on page 1 ........................................................................................................7a.                                                    . 00 

                                                                                                                                                                                                  00 
  8a. Nonbusiness income tax liability on line 7a (see instructions for tax tables)...............................................8a.                                                             . 
                                                                                                                                                                                                  00 
  8b. Business income tax liability (include Ohio Schedule IT BUS, line 14) .......................................................8b.                                                            . 
                                                                                                                                                                                                  00 
  8c. Income tax liability before credits (line 8a plus line 8b) ..............................................................................8c.                                                . 
                                                                                                                                                                                                  00 
  9. Ohio nonrefundable credits (include Ohio Schedule of Credits, line 34).......................................................9.                                                              . 
                                                                                                                                                                                                  00 
  10.Tax liability after nonrefundable credits (line 8c minus line 9; if less than -0-, enter -0-) .............................10.                                                               . 
 
    11. Interest penalty on underpayment of estimated tax (include Ohio IT/SD 2210)..........................................11.                                                                  . 00 
  12.Sales and use tax due on Internet, mail order or other out-of-state purchases (see instructions). 
    If you certify that no sales or use tax is due, check the box to the right ..........................................                      ....12.                                            .00 

                                                                                                                                                                                                  00 
  13.Total Ohio tax liability before withholding or estimated payments (add lines 10, 11 and 12) ...................13.                                                                           . 
  14.Ohio income tax withheld (W-2, box 17; W-2G, box 15; 1099-R, box 12). Include W-2(s), W-2G(s)                                                                                                00 
    and 1099-R(s) with the return .....................................................................................................................14.                                        . 
  15. Estimated and extension payments made (2016 Ohio IT 1040ES and/or IT 40P) and credit                                                                                                        00 
    carryforward from previous year return .........................................................................................................15.                                           . 
                                                                                                                                                                                                  00 
  16.Refundable credits (include Ohio Schedule of Credits, line 41) ..................................................................16.                                                         . 
                                                                                                                                                                                                  00 
  17.Amended return only – amount previously paid with original/amended return.........................................17.                                                                        . 
                                                                                                                                                                                                  00 
  18.Total Ohio tax payments (add lines 14, 15, 16 and 17) ............................................................................18.                                                        . 
                                                                                                                                                                                                  00 
  19.Amended return only – overpayment previously requested on original/amended return .........................19.                                                                               . 
                                                                                                                                                                                                  00 
  20.Line 18 minus line 19. Place a negative sign (“-“) before the ﬁgure if the amount is less than -0- ................20.                                                                       . 
 
           If line 20 is MORE THAN line 13, skip to line 24. OTHERWISE, continue to line 21. 

  21.Tax liability (line 13 minus line 20). If line 20 is negative, ignore the negative sign ("-") and add line                                                                                   00 
    20 to line 13.................................................................................................................................................21.                             . 
  22. Interest and penalty due on late  ﬁling or late payment of tax (see instructions) ..............................................................22.                                         00 
                                                                                                                                                                                                  . 
  23.TOTAL AMOUNT DUE (line 21 plus line 22). Include Ohio IT 40P (if original return) or IT 40XP 
    (if amended return) and make check payable to “Ohio Treasurer of State” ......... AMOUNT DUE23.                                                                                              00 
                                                                                                                                                                                                  . 
                                                                                                                                                                                                  00 
  24.Overpayment (line 20 minus line 13) ..........................................................................................................24.                                            . 
 
  25.Original return only  – amount of line 24 to be credited toward 2017 income tax liability ............................25.                                                                    00 
                                                                                                                                                                                                  . 
  26.Amount of line 24 to be donated: 
        a. Wildlife species         b. Military injury relief        c. Ohio History Fund 
                        . 00                               00                             00 
                                                          .                             . 
        d. State nature preserves   e. Breast / cervical cancer      f. Wishes for Sick Children 
                            00                             00                             00                                                                                                      00 
                        .                                 .                             .                         Total ....26g.                                                                  . 
  27. REFUND (line 24 minus lines 25 and 26g) .................................................................YOUR  REFUND27.                                                                   . 00 
    Sign Here (required): I have read this return. Under penalties of perjury, I declare that, to                          If your refund is $1.00 or less, no refund will be issued. 
    the best of my knowledge and belief, the return and all enclosures are true, correct and complete.                                         If you owe $1.00 or less, no payment is necessary. 
                                                                                                                                               NO Payment Included   Mail–                    to: 
 
       Your signature                                                           Date (MM/DD/YY)                                                                       Ohio Department of Taxation 
                                                                                                                                                                      P.O. Box 2679 
                                                                                                                                                                      Columbus, OH  43270-2679 
 Spouse’s signature (see instructions)                                         Phone number 
                                                                                                                                                                      Payment Included  –Mail to: 
                                                                                                                                                                      Ohio Department of Taxation 
        Preparer’s printed name (see instructions)        PTIN                  Phone number                                                                          P.O. Box 2057 
       Do you authorize your preparer to contact us regarding this return?      Yes                            No                                                     Columbus, OH  43270-2057 

                                                                                                                           2016 IT 1040 – page 2 of 2 

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Depa~ment of
* Ohio I Taxation 2016 Ohio Schedule A *
Rev. 9/16 Income Adjustments – Additions and Deductions 1111111111 1111 1111111111
SSN of primary ﬁler 

Additions
(add income items only to the extent not included on Ohio IT 1040, line 1)
00
1. Non-Ohio state or local government interest and dividends ....................................................................... 1. .
2. Certain Ohio pass-through entity and ﬁnancial institutions taxes paid ....................................................... 2. .00
3. Reimbursement of college tuition expenses and fees deducted in any previous year(s) and
noneducation expenditures from a college savings account ...................................................................... 3. . 00
00
4. Losses from sale or disposition of Ohio public obligations ......................................................................... 4. .
00
5. Nonmedical withdrawals from a medical savings account ......................................................................... 5. .
6. Reimbursement of expenses previously deducted for Ohio income tax purposes, but only if the 00
reimbursement is not in federal adjusted gross income ............................................................................. 6. .
Federal
00
7. Adjustment for Internal Revenue Code sections 168(k) and 179 depreciation expense ................7. .
00
8. Federal interest and dividends subject to state taxation ................................................................8. .
00
9. Miscellaneous federal income tax additions ...................................................................................9. .
00
10. Total additions (add lines 1 through 9 ONLY). Enter here and on Ohio IT 1040, line 2a ..............10. .

Deductions
(deduct income items only to the extent included on Ohio IT 1040, line 1)
00
11. Business income deduction (include Ohio Schedule IT BUS, line 11) ..................................................... 11. .
00
12. Employee compensation earned in Ohio by residents of neighboring states ............................................. 12. .
13. State or municipal income tax overpayments shown on the federal 1040, line 10 ................................... 13. . 00
00
14. Qualifying Social Security beneﬁts and certain railroad retirement beneﬁ ts ............................................ 14. .
15. Interest income from Ohio public obligations and from Ohio purchase obligations; gains from the
sale or disposition of Ohio public obligations; public service payments received from the state of 00
Ohio; or income from a transfer agreement ............................................................................................. 15. .
00
16. Amounts contributed to an individual development account .................................................................... 16. .
00
17. Amounts contributed to STABLE account: Ohio's ABLE Plan ..................................................................17. .
Federal
00
18. Federal interest and dividends exempt from state taxation ...................................................................... 18. .
00
19. Adjustment for Internal Revenue Code sections 168(k) and 179 depreciation expense .......................... 19. .
20. Refund or reimbursements shown on the federal 1040, line 21 for itemized deductions claimed on a
00
prior year federal income tax return ......................................................................................................... 20. .
21. Repayment of income reported in a prior year ......................................................................................... 21. . 00

22. Wage expense not deducted due to claiming the federal work opportunity tax credit.............................. 22. . 00

23. Miscellaneous federal income tax deductions .......................................................................................... 23. . 00

2016 Ohio Schedule A – pg. 1 of 2

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Depa~ment of
* Ohio I Taxation 2016 Ohio Schedule A *
Rev. 9/16 Income Adjustments – Additions and Deductions 1111111111 11111111111111
SSN of primary ﬁler 

Uniformed Services
24. Military pay for Ohio residents received while the military member was stationed outside Ohio ............. 24. . 00
00
25. Certain income earned by military nonresidents and civilian nonresident spouses ................................... 25. .
00
26. Uniformed services retirement income ..................................................................................................... 26. .
00
27. Military injury relief fund ....................................................................................................................................... 27. .
00
28. Certain Ohio National Guard reimbursements and beneﬁ ts ..................................................................... 28. .

Education
00
29. Ohio 529 contributions, tuition credit purchases ...................................................................................... 29. .
00
30. Pell/Ohio College Opportunity taxable grant amounts used to pay room and board ............................... 30. .
Medical
00
31. Disability and survivorship beneﬁts (do not include pension continuation beneﬁ ts) .....................31. .
32. Unreimbursed long-term care insurance premiums, unsubsidized health care insurance 00
premiums and excess health care expenses (see instructions for worksheet) ............................32. .
33. Funds deposited into, and earnings of, a medical savings account for eligible health care 00
expenses (see instructions for worksheet) ...................................................................................33. .
00
34. Qualiﬁ ed organ donor expenses (maximum $10,000 per taxpayer) ..........................................34. .
00
35. Total deductions (add lines 11 through 34 ONLY). Enter here and on Ohio IT 1040, line 2b ...............35. .

2016 Ohio Schedule A – pg. 2 of 2

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Depa!1ment of
* Ohio I Taxation 2016 Ohio Schedule IT BUS
Rev. 10/16 Business Income 11111111111111111 1111111 *
16260106
Include on this Ohio Schedule IT BUS any income included in federal adjusted gross income that constitutes business income. See Ohio
Revised Code (R.C.) section 5747.01(B). On page 2 of this schedule, list the sources of business income and your ownership percentage.
Include the Ohio Schedule IT BUS with Ohio IT 1040 if ﬁ ling by paper (see instructions if ﬁ ling electronically).
SSN of primary ﬁler Check to indicate which taxpayer earned this income:
Primary Spouse
Part 1 – Business Income From IRS Schedules
Note: Do not include amounts listed on these IRS schedules that are nonbusiness income.
See R.C. 5747.01(C). Place a negative sign (“-“) before the ﬁ gure if the amount is less than -0-.
00
1. Schedule B – Interest and Ordinary Dividends ........................................................................ 1. .

00
2. Schedule C – Proﬁt or Loss From Business (Sole Proprietorship) .......................................... 2. .

00
3. Schedule D – Capital Gains and Losses.................................................................................. 3. .

00
4. Schedule E – Supplemental Income and Loss ........................................................................ 4. .
5. Guaranteed payments, compensation and/or wages from each pass-through entity in
which you have at least a 20% direct or indirect ownership interest. Note: Reciprocity
00
agreements do not apply.......................................................................................................... 5. .
00
6. Schedule F – Proﬁt or Loss From Farming .............................................................................. 6. .
7. Other items of income and gain separately stated on the federal Schedule K-1, gains
and/or losses reported on the federal 4797 and miscellaneous federal income tax
00
adjustments, if any ................................................................................................................... 7. .
00
8. Total of business income (add lines 1 through 7) ..................................................................... 8. .

Part 2 – Business Income Deduction
9. All business income (enter the lesser of line 8 above or Ohio IT 1040, line 1). If -0-
00
or negative, stop here and do not complete Part 3 .................................................................. 9. .
10. Enter $250,000 if ﬁling status is single or married ﬁling jointly; OR
00
Enter $125,000 if ﬁling status is married ﬁ ling separately ...................................................... 10. .
00
11. Enter lesser of line 9 or line 10. Enter here and on Ohio Schedule A, line 11 .........................11. .
Part 3 – Taxable Business Income
Note: If Ohio IT 1040, line 5 equals -0-, do not complete Part 3.

00
12. Line 9 minus line 11 ................................................................................................................ 12. .
13. Taxable business income (enter the lesser of line 12 above or Ohio IT 1040, line 5).
00
Enter here and on Ohio IT 1040, line 6 .................................................................................. 13. .
14. Business income tax liability – multiply line 13 by 3% (.03). Enter here and on Ohio IT 1040,
00
line 8b ..................................................................................................................................... 14. .

Do not write in this area; for department use only.

2016 Ohio Schedule IT BUS – pg. 1 of 2

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                   Depa!1ment of 
*   Ohio I Taxation              2016 Ohio Schedule IT BUS 
                   Rev. 10/16 
                                 Business Income                        IIII I llll 111111111111111                   *  
                                                                               16260206
                                 SSN of primary ﬁler 

Part 4 – Business Entity 
If you have more than 18 entities, complete additional copies of this page and include with your income tax return. 
1.  Name of entity               FEIN/SSN                                      Percentage of ownership 

                                                                                                                    . 
2.  Name of entity               FEIN/SSN                                      Percentage of ownership 

                                                                                                                    . 
3.  Name of entity               FEIN/SSN                                      Percentage of ownership 

                                                                                                                    . 
4.  Name of entity               FEIN/SSN                                      Percentage of ownership 

                                                                                                                    . 
5.  Name of entity               FEIN/SSN                                      Percentage of ownership 

                                                                                                                    . 
6.  Name of entity               FEIN/SSN                                      Percentage of ownership 

                                                                                                                    . 
7.  Name of entity               FEIN/SSN                                      Percentage of ownership 

                                                                                                                    . 
8.  Name of entity               FEIN/SSN                                      Percentage of ownership 

                                                                                                                    . 
9.  Name of entity               FEIN/SSN                                      Percentage of ownership 

                                                                                                                    . 
10. Name of entity               FEIN/SSN                                      Percentage of ownership 

                                                                                                                    . 
11. Name of entity               FEIN/SSN                                      Percentage of ownership 

                                                                                                                    . 
12. Name of entity               FEIN/SSN                                      Percentage of ownership 

                                                                                                                    . 
13. Name of entity               FEIN/SSN                                      Percentage of ownership 

                                                                                                                    . 
14. Name of entity               FEIN/SSN                                      Percentage of ownership 

                                                                                                                    . 
15. Name of entity               FEIN/SSN                                      Percentage of ownership 

                                                                                                                    . 
16. Name of entity               FEIN/SSN                                      Percentage of ownership 

                                                                                                                    . 
17. Name of entity               FEIN/SSN                                      Percentage of ownership 

                                                                                                                    . 
18. Name of entity               FEIN/SSN                                      Percentage of ownership 

                                                                                                                    . 
                                 2016 Ohio Schedule IT BUS – pg. 2 of 2 
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                                                          Do not use staples. Use only black ink. 
               Depa~ment of 
*  Ohio I Taxation                          2016 Ohio Schedule of Credits 
               Rev. 9/16                                  Nonrefundable and Refundable                                                                                 11111111111111111 1111111 *  
                                                             SSN of primary ﬁler                                                                                       16280106

                                            Nonrefundable Credits
                                                                                                                                                                                         00 
   1. Tax liability before credits (from Ohio IT 1040, line 8c) ............................................................................... 1.                                       . 
   2.   Retirement income credit (limit $200 per return). See the table in the instructions ................................... 2.                                                       . 00 
   3.  Lump sum retirement credit (include Ohio LS WKS, line 6)… ..................................................................3.                                                    . 00 
                                                                                                                                                                                                 00 
   4.  Senior citizen credit (must be 65 or older to claim this credit; limit $50 per return) ................................ 4.                                                        . 
 
                                                                                                                                                                                                 00 
   5.  Lump sum distribution credit (must be 65 or older to claim this credit; include Ohio LS WKS, line 3)… .. 5.                                                                       . 
                                                                                                                                                                                                 00 
   6.  Child care and dependent care credit (see the worksheet in the instructions)… ...................................... 6.                                                           . 
 
                                                                                                                                                                                                 00 
   7.  If Ohio IT 1040, line 5 is $10,000 or less, enter $88; otherwise, enter -0- (low income credit) ................. 7.                                                              . 
   8.  Displaced worker training credit (see the worksheet in the instructions) (limit $500 per 
                                                                                                                                                                                                 00 
      taxpayer) .................................................................................................................................................. 8.                    . 
                                                                                                                                                                                                 00 
   9.  Campaign contribution credit for Ohio statewide ofﬁ ce or General Assembly (limit $50 per taxpayer) .. 9.                                                                         . 
                                                                                                                                                                                                 00 
   10.  Income-based exemption credit ($20 personal/dependent exemption credit) ........................................ 10.                                                             . 
 
                                                                                                                                                                                         00 
  11.  Total (add lines 2 through 10) ................................................................................................................. 11.                              . 
  12.  Tax less credits (line 1 minus line 11; if less than -0-, enter -0-) ............................................................. 12.                                            . 00 
 13.  Joint ﬁ ling credit. See the instructions for eligibility and documentation requirements. This credit is for  
      married   ﬁling jointly status only.  % times amount on line 12 (limit $650) ................................................13.                                                   . 00 
                                                                                                                                                                                                 00 
  14.  Earned income credit .............................................................................................................................. 14.                           . 
                                                                                                                                                                                                 00 
  15.  Ohio adoption credit (limit $10,000 per adopted child) ........................................................................ 15.                                               . 
                                                                                                                                                                                                 00 
  16.  Job retention credit, nonrefundable portion (include a copy of the credit certiﬁ cate) .............................. 16.                                                         . 
                                                                                                                                                                                                 00 
  17.  Credit for eligible new employees in an enterprise zone (include a copy of the credit certiﬁ cate) .......... 17.                                                                 . 
                                                                                                                                                                                                 00 
  18.  Credit for purchases of grape production property ................................................................................. 18.                                           . 
                                                                                                                                                                                         00 
  19.  Invest Ohio credit (include a copy of the credit certiﬁ cate) ..................................................................... 19.                                           . 
  20.  Technology investment credit carryforward (include a copy of the credit certiﬁ cate) .............................. 20.                                                           . 00 

                                                                                                                                                                                                 00 
  21.  Enterprise zone day care and training credits (include a copy of the credit certiﬁ cate) .......................... 21.                                                           . 
                                                                                                                                                                                                 00 
  22.  Research and development credit (include a copy of the credit certiﬁ cate) ............................................ 22.                                                       . 
  23.  Ohio historic preservation credit, nonrefundable carryforward portion (include a copy of the credit 
                                                                                                                                                                                         00 
      certiﬁ cate) ............................................................................................................................................... 23.                   . 
                                                                                                                                                                                                 00 
  24.  Total (add lines 13 through 23) ............................................................................................................... 24.                               . 
  25. Tax less additional credits (line 12 minus line 24; if less than -0-, enter -0-) ........................................... 25.                                                   . 00 

                                            Do not write in this area; for department use only. 

                                            2016 Ohio Schedule of Credits – pg. 1 of 2 

*                                                                                                                                                                                                *

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Depa~ment of
* Ohio I Taxation 2016 Ohio Schedule of Credits *
Rev. 9/16 Nonrefundable and Refundable IIII I Ill 1111111111111111
SSN of primary ﬁler 16280206

Nonresident Credit
Date of nonresidency to State of residency
26. Enter the portion of Ohio adjusted gross income (Ohio
IT 1040, line 3) that was not earned or received in
00
Ohio. Include Ohio IT NRC if required ...............................26. .
27. Enter the Ohio adjusted gross income (Ohio IT 1040,
00
line 3) ....................................................................................27. .

28. Divide line 26 by line 27 and enter the result here (four digits; do not round). . 00
Multiply this factor by the amount on line 25 to calculate your nonresident credit .................................... 28. .
Resident Credit
29. Enter the portion of Ohio adjusted gross income (Ohio
IT 1040, line 3) subjected to tax by other states or the
District of Columbia while you were an Ohio resident
(limits apply) ..................................................................... 29. . 00
30. Enter the Ohio adjusted gross income (Ohio IT 1040,
line 3) .............................................................................30. . 00
31. Divide line 29 by line 30 and enter the result here (four digits; do not round)..
Multiply this factor by the amount on line 25 and enter
the result here ................................................................31. 00
.
32. Enter the 2016 income tax, less all credits other than
withholding and estimated tax payments and overpayment
carryforwards from previous years, paid to other states or
the District of Columbia (limits apply) ............................. 32. . 00
33. Enter the smaller of line 31 or line 32. This is your Ohio resident tax credit. If you ﬁled a return for
2016 with a state(s) other than Ohio, enter the two-letter state abbreviation in the box(es) below ........ 33. . 00

34. Total nonrefundable credits (add lines 11, 24, 28 and 33; enter here and on Ohio IT 1040, line 9) .... 34. . 00

Refundable Credits
00
35. Historic preservation credit (include a copy of the credit certiﬁ cate) ....................................................... 35. .

00
36. Business jobs credit (include a copy of the credit certiﬁ cate) .................................................................... 36. .
00
37. Pass-through entity credit (include a copy of the federal K-1s) .............................................................. 37. .
00
38. Motion picture production credit (include a copy of the credit certiﬁ cate) ............................................... 38. .

00
39. Financial Institutions Tax (FIT) credit (include a copy of the federal K-1s).............................................. 39. .
00
40. Venture capital credit (include a copy of the credit certiﬁ cate) ................................................................ 40. .
00
41. Total refundable credits (add lines 35 through 40; enter here and on Ohio IT 1040, line 16) .............. 41. .

2016 Ohio Schedule of Credits – pg. 2 of 2

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                                     Do not use staples. Use only black ink and UPPERCASE letters. 
                Depa~ment of                 2016 Ohio Schedule J 
*  Ohio I Taxation 
                Rev. 9/16                    Dependents Claimed on the Ohio IT 1040 Return         11111111111111111           1111111 *  
                                             SSN of primary ﬁler                                   

Do not list below the primary ﬁ ler and/or spouse reported on Ohio IT 1040. Use this schedule to claim dependents. If you have more than 15 dependents,  
complete additional copies of this schedule and include them with your income tax return. Abbreviate the “Dependent’s relationship to you” below if there are  
not enough boxes to spell it out completely. 
 1. Dependent’s SSN (required)               Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name (required)         M.I.  Last name (required) 

2. Dependent’s SSN (required)                Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name (required)         M.I.  Last name (required)

3. Dependent’s SSN (required)                Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name (required)         M.I.  Last name (required)

4. Dependent’s SSN (required)                Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name (required)         M.I.  Last name (required)

5. Dependent’s SSN (required)                Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name (required)         M.I.  Last name (required)

6. Dependent’s SSN (required)                Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name (required)         M.I.  Last name (required)

7. Dependent’s SSN (required)                Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name (required)         M.I.  Last name (required)

                                             Do not write in this area; for department use only. 

                                             2016 Ohio Schedule J – pg. 1 of 2 

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                Depa!1ment of                 2016 Ohio Schedule J                                                              *  
*  Ohio I Taxation 
                Rev. 9/16                     Dependents Claimed on the Ohio IT 1040 Return IIIII IllI 111111111111111 
                                                         SSN of primary ﬁler                       

Do not list below the primary ﬁ ler and/or spouse reported on Ohio IT 1040. Use this schedule to claim dependents. If you have more than 15 dependents,  
complete additional copies of this schedule and include them with your income tax return. Abbreviate the “Dependent’s relationship to you” below if there are  
not enough boxes to spell it out completely.  
8. Dependent’s SSN (required)                 Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name (required)          M.I.  Last name (required) 

9. Dependent’s SSN (required)                 Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name (required)          M.I.  Last name (required)

  10. Dependent’s SSN (required)              Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name (required)          M.I.  Last name (required)

  11.  Dependent’s SSN (required)             Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name (required)          M.I. Last name (required) 

  12. Dependent’s SSN (required)              Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name (required)          M.I.  Last name (required)

  13. Dependent’s SSN (required)              Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name (required)          M.I.  Last name (required)

  14. Dependent’s SSN (required)              Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name (required)          M.I.  Last name (required)

15. Dependent’s SSN (required)                Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name (required)          M.I.  Last name (required)

                                              2016 Ohio Schedule J – pg. 2 of 2 

*                                                                                                                               *

- 11 -

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          Electronic Payment Available                                                                              2016 Ohio IT 40P 
You can eliminate writing a paper check by using any of 
our electronic payment methods. Go to our Web site at 
tax.ohio.gov for all electronic payment options. 

               Federal Privacy Act Notice 
Because we require you to provide us with a Social Se-
curity number, the        Federal Privacy Act of 1974 requires 
us to inform you that providing us with your Social Secu-
rity number is mandatory. Ohio Revised Code sections 
5703.05, 5703.057 and 5747.08 authorize us to request 
this information. We need your Social Security number in 
order to administer this tax. 

OHIO IT 40P                               Rev. 6/16 
                                                                                              Taxable Year      Do NOT fold check or voucher. 
Income Tax Payment Voucher                                     OTHERWISEDO NOT STAPLEATTACHOR 
                                                               YOUR PAYMENT TO                                                                               *  
                                                               THIS VOUCHER.                                             Use UPPERCASE letters
1.1•• 1••11 •••1.1•••111••1••••11.11••11 •••••1.1 •• 11.1      DO NOT SEND CASH.              2016                       to print the ﬁ rst three letters of 
First name                                M.I.       Last name                                                        Taxpayer’s            Spouse’s last name 
                                                                                                                      last name             (only if joint ﬁling) 
Spouse’s ﬁ rst name (only if joint ﬁling) M.I.       Last name 
                                                                                                                      I         I 
                                                                                                       Your SSN 
Address 
                                                                                                                    I 
                                                                                              Spouse’s SSN
                                                                                              (only if joint ﬁling) 
City, state, ZIP code                                                                                               I 

If you are sending this voucher and paper check or money order (payable to Ohio Treasurer 
                                                                                              Amount of
of State) with your income tax return, mail to the address shown on page 2 of Ohio IT 1040.                $                                              0 0
If you are sending ONLY this voucher and paper check or money order separately from the       Payment               i                             .          i 
return, then mail this voucher and payment to Ohio Department of Taxation, P.O. Box 182131, 
Columbus, OH 43218-2131.                                                                               .. 
                                                               402 
*

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