PDF document

- 1 -

                                                          Rev. 09/19/22
   Department of
   Taxation
hio

Scan Specifications for the 

2022 Ohio IT 1140

   Important Note

The following document (2022 Ohio IT 1140) contains grids for place-
ment of information on this specific tax form. To accurately print, do not 
reduce the size, rotate or center this document. Doing so jeopardizes 
the integrity of the grid. When printing from Adobe Reader, select 
“None” for “Page Scaling,” which is under “Page Handling.”

The 2022 Ohio IT 1140 test samples must be initially submitted 
by December 1, 2022 and approved no later than April 1, 2023. 

                        Ohio Department of Taxation

                        4485 Northland Ridge Blvd.

                        Columbus, OH 43229

                        tax.ohio.gov

- 2 -

Enlarge image

   Department of
   Taxation
hio

General information 

regarding this form

- 3 -

Enlarge image

    General Information (2022 Ohio IT 1140):
1) Dimensions: 
  
  Target or registration marks - 0.25” diameter circles. Follow grid layout for positioning.

  1D barcode (2 of 5 interleaved) - .375”H x 1.5”W. Follow grid layout for positioning. Center the barcode number 
   directly under the barcode.

  2D barcode (PDF 417) - See 2D instructions and schema. Follow grid layout for positioning. There is one 2D 
   barcode on each page of the Ohio IT 1140.

2) 1D barcode - The last two numbers of the 1D barcode represent the vendor number. Use the same vendor 
number as you did for last year’s return. If you have a question about your barcode assignment, e-mail the Forms 
Unit at Forms@tax.state.oh.us. The first six numbers are constant for this form (221701XX - 221707XX). 

  22 = tax year
  17 = Ohio IT 1140 
  01-07 = page number 
  XX = vendor number (assigned to you by the Ohio Dept. of Taxation, Forms Unit).

   NOTE: The vendor number also serves as the first two digits of the SSN and FEIN fields in the test 
   scenarios.

3) Use Arial or Courier font for the static text on the form. The static text for all target marks and header informa-
tion (target marks, logo, title and 1D barcode) must match grid. Note: Courier must be used for the static tax 
year in the form title.

4) Use Courier, monospaced Arial, or monospaced Sans-Serif font for the variable data fields on the form.

5) Follow the grid layout for the variable data fields shown in red. Ensure that the tax year, target or reg-
istration marks, “For Department Use Only” area and the 1D and 2D barcodes follow grid layout.

6) DO NOT USE COMMAS, HYPHENS OR DECIMALS IN THE VARIABLE DATA FIELDS EXCEPT WHERE 
SHOWN IN SPECS.

7) You must include a leading zero on ratio fields. For example, if the ratio is .000026, it should display as 0.000026.

8) The possible negative fields for this return are: both columns of line 4, both columns of line 9, both columns 
of line 12, line 25, and line 28. Do not hard-code negative signs.

9) Provide guidance to customers regarding duplex printing that instructs them to print pages 1 and 2 together 
and pages 3 and 4 together. Taxpayers have filed returns with pages 2 and 3 duplexed or a worksheet or software 
receipt on the back of a page of the return. This slows the processing of the tax return.

10) Any other documentation generate the following message for customers: “Do not enclose other docu-
mentation unless it is specified on the tax return or instructions.” Taxpayers often submit worksheets and 
receipts from the vendor product, which slows the processing of tax returns. Any other documentation generated 
from the software must include a 1D barcode identifying it as an additional information. The preferred placement 
is centered on the top edge of the page within the print area, however placement at any location on the page will 
be accepted. Always use the following 1D barcode (2 of 5 interleaved):

    10211411

11) The 1140 Schedule IV pages 4-7 can include up to 12 investors. Generate duplicate copies of page 7 to ac-
commodate any additional investors, however omit the standard 1D and 2D barcodes from the duplicate pages and 
include the 10211411 barcode indicated above.

- 4 -

Enlarge image

12) IMPORTANT NOTE: Add this statement to your software programs. It should print out with the taxpayer’s 
return. “Do not hand write in any corrections on the printed paper return. Hand writing in corrections will 
result in capturing incorrect data and delaying the processing of this income tax return. Make any cor-
rections to this income tax return within [the software program name], then print and mail.”

13) For all balance due returns, generate the proper payment voucher.

14)*Important Note* Non-applicable lines must populate blank in the 2D barcode and show blank on the forms 
unless otherwise described in the schema. Schema guidelines must be followed.

15) See the 2D barcode instructions for submission details.

- 5 -

Enlarge image

              Department of
              Taxation
hio

Additional  instructions  for 

the 2D barcode information, 

submission process, testing 

and notifications

              Important Note

It is required that vendors program the Ohio IT 1140 to include 2D barcodes.

- 6 -

Enlarge image

                                      2022 Ohio IT 1140

     Pass-Through Entity and Trust Withholding Tax Return

                                2D Barcode Instructions
General Information
 •  The Ohio IT 1140 must be enabled for 2D barcode decoding
 • A form enabled for 2D barcode should not allow users or practitioners the option to turn off/on the 2D barcode function
 •  The minimum error correction code level is 4
 •  Optimal dpi level is 300 dpi. The minimum dpi level is 200 dpi

2D Barcode Size and Placement on the Form
 •  2D barcode must be placed on each page of form in the designated area indicated in the grid layout
 • The maximum size of the 2D barcode is 3.5 inches wide by 1 inch in height and must fit within the designated space in the grid 
   layout
 •  2D barcode must not be bigger than the allocated area

2D Barcode Layout
 • Each field in the barcode is delimited by a single carriage return
   • <CR> equals single carriage return character
   • This separates each piece of data so it may be identified and processed.
 •  Data included in the 2D barcode can be broken down into three general sections
     Header
         Header Version Number
            • Static for all barcodes, value is T1
         Developer Code
            • A four-digit vendor code identifying the software developer whose application produced the barcode
         Jurisdiction
            • Static for all barcodes, value is OH
         Description
            • A four-digit form identifier, specific to each form
         Spec Version
            • A one-digit specification version control number starting with the number zero
            • This number identifies the version of the specifications used to produce the form barcode
         Form Version
            • A one-digit form version control number starting with the number one (1)
            • This number will only be incremented when there are changes made that would affect the content of the barcode
         Date Generated
            • Included on page 1 only
            • Indicates date return was generated from the product
 
     Form Specific Data – Please see encoding schemas for form specific data
         •  All fields on the form are required and must be included in the 2D barcode
         •  Fields with values are represented by the data followed by a carriage return
         •  Fields with no values are represented by a carriage return only; this results in two adjacent carriage returns
         •  Note that the data format within the 2D barcode for the Weight, Ratio and Weighted Ratio differs from the print ver-
            sion. Do not include the decimal point in the 2D data.
 
     Trailer
         •  The last field in the barcode data stream is the trailer
         •  The trailer is used to indicate the end of data has been reached
         •  A static string of *EOD* is used as the trailer value

     Examples of 2D Barcode data streams 
            Header Version Number T1<CR> 
            Developer Code 1111<CR> 
            Jurisdiction OH<CR>
            Description 2217<CR>
            Spec Version 0<CR> 
            Form Version 1<CR>
            Date Generated 011523<CR> 
            Line Item Specific Data IN<CR>
            Line Item Specific Data IT40<CR> 
            Line Item Specific Data 0<CR>
            Trailer *EOD* <CR>

- 7 -

Enlarge image

Submission Process
 • Test packets may be submitted by email to Forms@tax.state.oh.us
 • The email subject line must include the vendor number, product name, tax year and form number in that order e.g. 12_
   ABCTax_ 22_1140
 • Submissions must include
   • One (1) full field sample in a PDF format
   • Six (6) test scenarios for the Ohio IT 1140 provided by the Ohio Department of Taxation
     •       Each test scenario must be in a separate PDF using the following naming convention: vendor number, product name, 
             tax year, form number, test number e.g.12_ABCTax_22_1140_Test 1
   • An emailed confirmation is sent to the vendor indicating the packet was received
   • Submissions found to be missing any of the items above are rejected

Testing Process
 • Testing of Ohio IT 1140 bundle packets commences on October 31, 2022 
 • The deadline for an initial submission of Ohio IT 1140 bundle test packets is December 1, 2022 
 • The deadline for approval of Ohio IT 1140 bundle test packets is April 18, 2023
 • Test packets are reviewed in two (2) content areas- printed forms and 2D barcode data
 • A submission is approved in its entirety once all sample documents pass in both areas
   Printed forms
     •       Vendor full field matches template provided in the specifications
     •       All fields are present, are formatted properly and align with grid layout
     •       Test scenarios contain values specified by Ohio Department of Taxation
   2D Barcode Data
     •       Barcodes read as valid
     •       All test scenarios can be decoded
     •       2D barcode data matches data on printed forms

Additional Instructions
 • The static text for all target marks and header information (target marks, logo, title and 1D barcode) must match grid.
 • Any other documentation generated from the software must include a 1D barcode identifying it as an additional information. 
   The preferred placement is centered on the top edge of the page within the print area, however placement at any location on 
   the page will be accepted. Always use the following 1D barcode (2 of 5 interleaved):

     10211411

Notifications
 • Communications from the Ohio Department of Taxation regarding submissions are sent from Forms@tax.state.oh.us to the 
   vendor email address(es) on file for the product
 • Vendor contact information is compiled from STF- Approval Request for Scannable Tax Forms but may also be submitted by 
   email to the address above.
 • If unapproved forms are released in software packages, vendors must include a visual indicator signifying the return cannot be 
   filed.
 • If unapproved forms are released in software packages, vendors must ensure that taxpayers cannot print returns 
   containing 2D barcodes.
 • An emailed confirmation is sent to the vendor indicating the packet was approved, at which point the product is authorized to 
   print with a 2D barcode.
 • An emailed confirmation is sent to the vendor for packets that are rejected
     •       Feedback is provided regarding the errors found
     •       Resubmit packets must include all test scenarios and the full field return
     •       After the third submission of test materials, the department cannot guarantee timeliness of the review
     •       If a tax form changes before January 1, 2023 vendors will be notified and required to submit revised test packets.

- 8 -

Enlarge image

   Department of
   Taxation
hio

Grid layout

- 9 -

Enlarge image

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85
2
3                                                                    Do not staple or paper clip.
4
5                                                                                                                   2022    Ohio IT 1140 
6                                                                                       Rev. 07/25/22         Pass-Through Entity and 
7                                                                                                          Trust Withholding Tax Return                                                                                 22170110
8
                                                            88 88 88
9                                                                                                     Use only black ink and UPPERCASE letters. Use whole dollars only.
                                                                                                                                                                                                                        Reporting Period Start Date
10                                                            Check here if amended return              Check here if final return                                                 Check here if federal extension filed
                                                            X                                         X                               X
11
                                                                                                                                                                                                                        XX XX XX
12                                                          FEIN
13                                                                                                            Entity Type:         S corporation                                              Partnership               Reporting Period End Date
                                                            88 8888888                                        (check only one) X                                                           X
14                                                                                                                                 Limited liability company                                  Trust                     XX XX XX
                                                                                                                               X                                                           X
15                                                          Name of pass-through entity / trust
16
                                                            JOHNXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
17
18                                                          Address          Check here if address change
                                                                         X
19
                                                            8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
20                                                          City                                                                           State                                   ZIP code
21
                                                            CITYXXXXXXXXXXXXXXXX                                                           OH                                      88888
22
23                                                          Foreign State Code          Country Code          Foreign country (if the mailing address is outside the U.S.)                                              Foreign postal code
24                                                                   888                    88             88888888888888888888                                                                                         8888888
25                                                          Total number of investors    Number of investors /                   Ownership percentage of investors                                                      Apportionment ratio, line 24
26                                                          / beneficiaries              beneficiaries included on return        / beneficiaries on return
27
                                                            888888                       888888                                  8.8888                                                                                 8.888888
28
29                                                                           If the amount on a line is negative, place a “–” in the box provided. Note: No credits are allowed on the IT 1140.
30
                                                            Schedule I – Reconciliation Tax and Payments
31                                                                                                                             Column (A) – Withholding Tax                                             Column (B) – Entity Tax
32                                                           1.  Tax Liability from line 20, columns A and B or line 30 
33                                                                                                                                 888888888888                                                         888888888888

34                                                          2.  Interest Penalty (see instructions)
                                                                                                                                   888888888888                                                         888888888888
35                                                         2a.  Add lines 1 and 2
36                                                                                                                                 888888888888                                                         888888888888
                             Do not staple or paper clip.   3. Ohio IT 1140 estimated (UPC/electronic) payments and 2021
37                                                              overpayment credited to 2022
                                                                                                                                   888888888888                                                         888888888888
38
39                                                        3a. Ohio IT 4708, IT 4738 estimated (UPC/electronic) payments  
                                                            and prior year IT 4708 overpayment claimed on this return  
40                                                          (see instructions).
                                                                                                                                   888888888888
41
                                                           3b. Ohio IT 1140 estimated (UPC/electronic) payments claimed  
42                                                          on an IT 4708 instead of this return (see instructions).
                                                                                                                                   888888888888
43
44                                                        3c.  Net payments (sum of lines 3 and 3a minus line 3b) if
                                                                 negative, enter zero                                              888888888888                                                         888888888888
45
                                                           
46                                                        4.   For each column, subtract line 3c from line 2a                  -   888888888888                                                       - 888888888888
47
48                                                            5.  If the sum of line 4, columns A and B is an overpayment, enter that sum here................OVERPAYMENT
                                                                                                                                                                                                        888888888888
49                                                           5a. Amount of line 5 to beCREDITED toward next year’s liability (if this is an amended return, enter zero) ....
50                                                               ................................................................................................................. CREDIT CARRYFORWARD
                                                                                                                                                                                                        888888888888
51                                                           5b. Amount of line 5 to be REFUNDED (line 5 minus line 5a) ............................................................ REFUND
                                                                                                                                                                                                        888888888888
52
53                                                            6. If the sum of line 4, columns A and B is a balance due or zero, enter here
                                                                                                                                                                                                        888888888888
54                                                            7. Interest due on late payment of tax (see instructions)                                                                                 888888888888
55                                                            8.  Total amount due (add lines 6 and 7). Make check payable to Ohio Treasurer of State. 
56                                                               Include the Ohio IT 1140 UPC and write FEIN on check .....................................................AMOUNT DUE
                                                                                                                                                                                                        888888888888
57                                                                           If your refund is $1.00 or less, no refund will be issued. If you owe $1.00 or less, no payment is necessary.
58
59
60
61                                                                        Software vendors: Place 2D barcode in this location                                                                           MM DD           YY      CODE
62                                                                        Do not place a box around the 2D barcode. The box
63                                                                                    is only here for placement purposes.                                                         2022 IT 1140 – pg.   of17
64
65
66

- 10 -

Enlarge image

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85
2
3
4
5                                                                       2022 Ohio IT 1140
6                               Rev. 07/25/22
7                                                                                                                             22170210
8  FEIN
9
   88 8888888
10
11 Sign Here (required): I have read this return. Under penalties of perjury, I declare that, to 
12 the best of my knowledge and belief, the return and all enclosures are true, correct and complete.             Do not staple or paper clip. 
13                                                                                                       Place any supporting documents, including 
                                                                                                         Ohio IT K-1s, after the last page of this return.
14 Pass-through entity officer or agent (print)  
15
16 Title of officer or agent (print)                                Phone number                                              Mail to: 
17                                                                                                            Ohio Dept. of Taxation
18 Signature of pass-through officer or agent                       Date (MM/DD/YY)
                                                                                                                              P.O. Box 181140
19
   Preparer’s name (print)                                          Phone number                              Columbus, OH 43218-1140
20
21 Preparer’s e-mail address                                                              PTIN P 88888888
22                                                                                                               Instructions for this form are
23 Check here if you authorize your preparer to contact us regarding this return                                              available at tax.ohio.gov. 
                                                                                                 X
24
25                                                       If the amount on a line is negative, place a “–” in the box provided.
26 Schedule II – Qualifying Pass-Through Entities – Tax Due
27 Use this schedule to calculate the pass-through entity’s adjusted qualifying amount of business income and tax due before payments.  
28 See instructions for all line item explanations found at tax.ohio.gov along with FAQs. 
29                                                                      Column (A) – Withholding Tax                          Column (B) – Entity Tax
30
     9.  Qualifying investors’ distributive shares of income, gain, 
31     expense and loss                                                 -                                        -
                                                                                   888888888888                               888888888888
32
33  
34 10.  IRC §168(k) bonus depreciation and §179 expense and  
       Ohio authorized federal conformity add-back                                 888888888888                               888888888888
35
36 10a.  X   2/3,         X 5/6 or          X6/6  (check applicable box)
37
38 11.  IRC  §168(k) bonus depreciation and §179 expense 
       deductions from schedule V and Ohio authorized federal 
39     conformity deductions (see instructions if filing as invest-
40     ment pass-through entity)
41                                                                                 888888888888                               888888888888
42  12.  Sum of lines 9 and 10 minus line 11                            -          888888888888                  -            888888888888
43
44 13. Related members add-back (see instructions for complete 
45     list of related members)
                                                                                   888888888888                               888888888888
46
47
   14.  Guaranteed payments add-back (20% or greater investors 
48     only) 
                                                                                   888888888888                               888888888888
49
50 15. Compensation add-back (20% or greater investors only) 
                                                                                   888888888888                               888888888888
51
52
53
54
55
56
57
58
59
60
61           Software vendors: Place 2D barcode in this location
62           Do not place a box around the 2D barcode. The box
63                              is only here for placement purposes.                                     2022 IT 1140 – pg.   of27
64
65
66

- 11 -

Enlarge image

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85
2
3
4
5                                                    2022 Ohio IT 1140
6                              Rev. 07/25/22
7                                                                                                                    22170310
8  FEIN
9
   88 8888888
10
11 Schedule II – Qualifying Pass-Through Entities – Tax Due...continued.
12                                                   Column (A) – Withholding Tax                                   Column (B) – Entity Tax
13 16.  Sum of lines 12, 13, 14 and 15 
14     (if negative, enter “0”)
                                                     888888888888                                                   888888888888
15
16  17.  Apportionment ratio from line 24
                                                     8.888888                                                         8.888888
17
18
19 18. Adjusted qualifying amount (multiply 
    lines 16 and 17). If the sum of line 18 
20  exceeds $1,000 continue to line 20
                                                     888888888888                                                   888888888888
21
22 19. Tax rate                                           X .05                                                       X .085
23
24 20. Tax due (multiply lines 18 and 19).
    Enter here and on the corresponding 
25  column of line 1
26                                                   888888888888                                                   888888888888
27
28
   Schedule III – Qualifying Pass-Through Entities – Apportionment Worksheet
29
   Calculate the apportionment ratio for a pass-through entity that is not a financial institution.  See instructions for calculation of financial institutions.  
30 Note: ratios must carry to six decimal places. 
31
32   21.  Property                                   Within Ohio                                                    Total Everywhere
33
      a) Owned (original cost)                       888888888888                                                   888888888888
34                                                   Within Ohio                                                    Total Everywhere
35    b) Rented (annual rental X 8)                  
                                                     888888888888                                                   888888888888
36                                                   Within Ohio                                                    Total Everywhere
37    c) Total (lines 21a and 21b)                   888888888888                 ÷                                 888888888888
38
39                                                                  Ratio              Weight                         Weighted Ratio
                                                                                                                      8.888888
40                                                        =         8.888888        x  8.88                         =
41                                                   Within Ohio                                                    Total Everywhere
42 22.  Payroll                                      888888888888                 ÷
                                                                                                                    888888888888
43                                                                  Ratio              Weight                         Weighted Ratio
44                                                        =         8.888888        x  8.88                         = 8.888888
45                                                   Within Ohio                                                    Total Everywhere
46   23.  Sales                                      888888888888                 ÷                                 888888888888
47                                                                  Ratio              Weight                         Weighted Ratio
48                                                        =         8.888888        x  8.88                         = 8.888888
49
50
51
     24.  Ohio apportionment ratio (add lines 21c, 22 and 23). Enter ratio here and on line 17 above (both columns)   8.888888
52
53 Note: If the “Total Everywhere” of any factor is zero, the weight given to the other factors must be proportionately increased so that the total weight given 
   to the combined number of factors used is 100%, i.e., if no property/payroll, use 25% and 75%; if no sales, use 50% property/payroll; if only one factor, 
54 use 100%.
55
56
57
58
59
60
61                 Software vendors: Place 2D barcode in this location
62                 Do not place a box around the 2D barcode. The box
63                             is only here for placement purposes.               2022 IT 1140 – pg.   of37
64
65
66

- 12 -

Enlarge image

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85
2
3
4
5                                                                             2022 Ohio IT 1140
6                                       Rev. 07/25/22
7                                                                                                                                     22170410
8  FEIN
9
   88 8888888
10
11 Schedule IV – Trusts – Tax Due
   Use this schedule to calculate the adjusted qualifying amount and tax due before payments for nonresident individual beneficiaries of a trust. See instruc-
12 tions for all line-item explanations found at tax.ohio.gov along with FAQs.
13
14 25.  Sum of all distributions to nonresident individuals of income or gain attributable to the trust’s ownership 
                                                                                                                      888888888888
15     of or disposition of either tangible personal property located in Ohio or real property located in Ohio      -
16
   26.  IRC  §168(k) bonus depreciation and §179 expense and Ohio authorized federal conformity 
17
       add-back                                                                                                       888888888888
18    26a.            X 2/3           X 5/6            X   6/6
19
20  27.  IRC  §168(k) bonus depreciation and §179 expense deductions from Schedule V and Ohio 
       authorized federal conformity deductions                                                                       888888888888
21  

22 28.  Sum of line 25 and 26 minus line 27                                                                         - 888888888888
23
   29.  Tax rate                                                                                                                                                  X .05
24
25 30.  Tax due: multiply lines 28 and 29. Enter here and on line 1, column A                
                                                                                                                      888888888888
26
27 Schedule V – IRC §168K Bonus Depreciation and §179 Expense Add-Back Schedule 
28 Use this schedule to report current year IRC §168K Bonus Depreciation and IRC §179 Expense add-back and deductions from prior years Ohio add-
29 backs.  See instructions for calculation tables.
30        Check the box if partial or full depreciation add-back has been waived.
      X  
31 31. Current year IRC §168(k) bonus depreciation and IRC §179 expense add-back
                                                                                                                      888888888888
32 32. Prior years Ohio add-back amount and applicable add-back ratio from Ohio filed returns
33                                                            Column (A) – Amount                         Column (B) – Ratio
34
35 32a. Year Prior       .....................................................888888888888         X             2/3                X 5/6                  X   6/6
36     

37 32b. 2 Years Prior    ................................................888888888888              X             2/3                X 5/6                  X   6/6
38   
39 32c. 3 Years Prior    ................................................888888888888              X             2/3                X 5/6                  X   6/6
40
    
41 32d. 4 Years Prior    ................................................888888888888              X             2/3                X 5/6                  X   6/6
42   
    
43 32e. 5 Years Prior    ................................................888888888888              X             2/3                X 5/6                  X   6/6
44
45 Schedule VI – Investor Information
46 First list the investors whose income is included on the return in order from highest to lowest ownership percentage. Then list all remaining investors from highest 
   to lowest ownership percentage. Use additional sheets, if necessary.
47
48        Check here if the investor is included on the return.
      X  
49 SSN                                                        FEIN                          Percent of ownership    1140 Share of PTE tax credit
50
   888 88 8888                                                88 8888888                    8.8888                  888888888
51 First name / entity                                                        M.I. Last name
52                                                                                 PUBLICXXXXXXXXXXXXXX
   JOHNXXXXXXXXXXX
53                                                                            Q
   Address
54
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
55 City                                                                                     State ZIP code
56
57                                                                                          OH    88888
   CITYXXXXXXXXXXXXXXXX
58
59
60
61                      Software vendors: Place 2D barcode in this location
62                      Do not place a box around the 2D barcode. The box
63                                      is only here for placement purposes.                       2022 IT 1140 – pg.   of47
64
65
66

- 13 -

Enlarge image

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85
2
3
4
5                                        2022 Ohio IT 1140
6                      Rev. 07/25/22
7                                                                                                22170510
8  FEIN
9
   88 8888888
10
11
   Schedule VI – Investor Information...continued
12
13      Check here if the investor is included on the return.
   X  
14
15 SSN                              FEIN                                   Percent of ownership 1140 Share of PTE tax credit
16
   888 88 8888                      88 8888888                             8.8888               888888888
17 First name / entity                                       M.I. Last name
   JOHNXXXXXXXXXXX
18                                                                PUBLICXXXXXXXXXXXXXX
19                                                           Q
   Address
20
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
21 City                                                                    State ZIP code
22
   CITYXXXXXXXXXXXXXXXX                                                    OH    88888
23
24 X    Check here if the investor is included on the return.
25
26 SSN                              FEIN                                   Percent of ownership 1140 Share of PTE tax credit
27
   888 88 8888                      88 8888888                             8.8888               888888888
28 First name / entity                                       M.I. Last name
29                                                                PUBLICXXXXXXXXXXXXXX
   JOHNXXXXXXXXXXX                                           Q
30 Address
31
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
32 City                                                                    State ZIP code
33
   CITYXXXXXXXXXXXXXXXX                                                    OH    88888
34
35 X    Check here if the investor is included on the return.
36
37 SSN                              FEIN                                   Percent of ownership 1140 Share of PTE tax credit
38
   888 88 8888                      88 8888888                             8.8888               888888888
39 First name / entity                                       M.I. Last name
40                                                                PUBLICXXXXXXXXXXXXXX
   JOHNXXXXXXXXXXX                                           Q
41 Address
42
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
43 City                                                                    State ZIP code
44
   CITYXXXXXXXXXXXXXXXX                                                    OH    88888
45
46 X    Check here if the investor is included on the return.
47
48 SSN                              FEIN                                   Percent of ownership 1140 Share of PTE tax credit
49
   888 88 8888                      88 8888888                             8.8888               888888888
50 First name / entity                                       M.I. Last name
51                                                                PUBLICXXXXXXXXXXXXXX
   JOHNXXXXXXXXXXX                                           Q
52 Address
53
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
54 City                                                                    State ZIP code
55
   CITYXXXXXXXXXXXXXXXX                                                    OH    88888
56
57
58
59
60
61        Software vendors: Place 2D barcode in this location
62        Do not place a box around the 2D barcode. The box
63                     is only here for placement purposes.                       2022 IT 1140 – pg.   of57
64
65
66

- 14 -

Enlarge image

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85
2
3
4
5                                        2022 Ohio IT 1140
6                      Rev. 07/25/22
7                                                                                                22170610

8  FEIN
9
   88 8888888
10
11
   Schedule VI – Investor Information...continued
12
13      Check here if the investor is included on the return.
   X  
14
15 SSN                              FEIN                                   Percent of ownership 1140 Share of PTE tax credit
16
   888 88 8888                      88 8888888                             8.8888               888888888
17 First name / entity                                       M.I. Last name
   JOHNXXXXXXXXXXX
18                                                                PUBLICXXXXXXXXXXXXXX
19                                                           Q
   Address
20
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
21 City                                                                    State ZIP code
22
   CITYXXXXXXXXXXXXXXXX                                                    OH    88888
23
24 X    Check here if the investor is included on the return.
25
26 SSN                              FEIN                                   Percent of ownership 1140 Share of PTE tax credit
27
   888 88 8888                      88 8888888                             8.8888               888888888
28 First name / entity                                       M.I. Last name
29                                                                PUBLICXXXXXXXXXXXXXX
   JOHNXXXXXXXXXXX                                           Q
30 Address
31
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
32 City                                                                    State ZIP code
33
   CITYXXXXXXXXXXXXXXXX                                                    OH    88888
34
35 X    Check here if the investor is included on the return.
36
37 SSN                              FEIN                                   Percent of ownership 1140 Share of PTE tax credit
38
   888 88 8888                      88 8888888                             8.8888               888888888
39 First name / entity                                       M.I. Last name
40                                                                PUBLICXXXXXXXXXXXXXX
   JOHNXXXXXXXXXXX                                           Q
41 Address
42
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
43 City                                                                    State ZIP code
44
   CITYXXXXXXXXXXXXXXXX                                                    OH    88888
45
46 X    Check here if the investor is included on the return.
47
48 SSN                              FEIN                                   Percent of ownership 1140 Share of PTE tax credit
49
   888 88 8888                      88 8888888                             8.8888               888888888
50 First name / entity                                       M.I. Last name
51                                                                PUBLICXXXXXXXXXXXXXX
   JOHNXXXXXXXXXXX                                           Q
52 Address
53
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
54 City                                                                    State ZIP code
55
   CITYXXXXXXXXXXXXXXXX                                                    OH    88888
56
57
58
59
60
61        Software vendors: Place 2D barcode in this location
62        Do not place a box around the 2D barcode. The box
63                     is only here for placement purposes.                       2022 IT 1140 – pg.   of67
64
65
66

- 15 -

Enlarge image

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85
2
3
4
5                                        2022 Ohio IT 1140
6                      Rev. 07/25/22
7                                                                                                22170710

8  FEIN
9
   88 8888888
10
11
   Schedule VI – Investor Information...continued
12
13      Check here if the investor is included on the return.
   X  
14
15 SSN                              FEIN                                   Percent of ownership 1140 Share of PTE tax credit
16
   888 88 8888                      88 8888888                             8.8888               888888888
17 First name / entity                                       M.I. Last name
   JOHNXXXXXXXXXXX
18                                                                PUBLICXXXXXXXXXXXXXX
19                                                           Q
   Address
20
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
21 City                                                                    State ZIP code
22
   CITYXXXXXXXXXXXXXXXX                                                    OH    88888
23
24 X    Check here if the investor is included on the return.
25
26 SSN                              FEIN                                   Percent of ownership 1140 Share of PTE tax credit
27
   888 88 8888                      88 8888888                             8.8888               888888888
28 First name / entity                                       M.I. Last name
29                                                                PUBLICXXXXXXXXXXXXXX
   JOHNXXXXXXXXXXX                                           Q
30 Address
31
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
32 City                                                                    State ZIP code
33
   CITYXXXXXXXXXXXXXXXX                                                    OH    88888
34
35 X    Check here if the investor is included on the return.
36
37 SSN                              FEIN                                   Percent of ownership 1140 Share of PTE tax credit
38
   888 88 8888                      88 8888888                             8.8888               888888888
39 First name / entity                                       M.I. Last name
40                                                                PUBLICXXXXXXXXXXXXXX
   JOHNXXXXXXXXXXX                                           Q
41 Address
42
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
43 City                                                                    State ZIP code
44
   CITYXXXXXXXXXXXXXXXX                                                    OH    88888
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61        Software vendors: Place 2D barcode in this location
62        Do not place a box around the 2D barcode. The box
63                     is only here for placement purposes.                       2022 IT 1140 – pg.   of77
64
65
66

- 16 -

Enlarge image

   Department of
   Taxation
hio

   Layout 

without grid

- 17 -

Enlarge image

Do not staple or paper clip.
2022    Ohio IT 1140 
Rev. 07/25/22 Pass-Through Entity and 
Trust Withholding Tax Return 22170110

88 88 88 Use only black ink and UPPERCASE letters. Use whole dollars only.
Reporting Period Start Date
X Check here if amended return X Check here if final return X Check here if federal extension filed
XX XX XX
FEIN
Entity Type: S corporation   Partnership Reporting Period End Date
88 8888888 (check only one) X X
X Limited liability company X   Trust XX XX XX
Name of pass-through entity / trust
JOHNXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Address         XCheck here if address change
8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
City State ZIP code
CITYXXXXXXXXXXXXXXXX OH 88888
Foreign State Code Country Code Foreign country (if the mailing address is outside the U.S.) Foreign postal code
888 88 88888888888888888888 8888888
Total number of investors Number of investors / Ownership percentage of investors Apportionment ratio, line 24
/ beneficiaries beneficiaries included on return / beneficiaries on return
888888 888888 8.8888 8.888888

If the amount on a line is negative, place a “–” in the box provided. Note: No credits are allowed on the IT 1140.
Schedule I – Reconciliation Tax and Payments
Column (A) – Withholding Tax Column (B) – Entity Tax
 1.  Tax Liability from line 20, columns A and B or line 30 888888888888 888888888888

2.  Interest Penalty (see instructions) 888888888888 888888888888
 2a.  Add lines 1 and 2 888888888888 888888888888
Do not staple or paper clip. 3. Ohio IT 1140 estimated (UPC/electronic) payments and 2021
    overpayment credited to 2022 888888888888 888888888888
3a. Ohio IT 4708, IT 4738 estimated (UPC/electronic) payments  
 and prior year IT 4708 overpayment claimed on this return  
 (see instructions). 888888888888
 3b. Ohio IT 1140 estimated (UPC/electronic) payments claimed  
  on an IT 4708 instead of this return (see instructions). 888888888888
3c.  Net payments (sum of lines 3 and 3a minus line 3b) if
       negative, enter zero 888888888888 888888888888
 
4.   For each column, subtract line 3c from line 2a - 888888888888 - 888888888888
  5.  If the sum of line 4, columns A and B is an overpayment, enter that sum here................OVERPAYMENT 888888888888
 5a. Amount of line 5 to beCREDITED toward next year’s liability (if this is an amended return, enter zero) ....
 ................................................................................................................. CREDIT CARRYFORWARD
888888888888
 5b. Amount of line 5 to be REFUNDED (line 5 minus line 5a) ............................................................ REFUND 888888888888

  6. If the sum of line 4, columns A and B is a balance due or zero, enter here 888888888888
  7. Interest due on late payment of tax (see instructions) 888888888888
  8.  Total amount due (add lines 6 and 7). Make check payable to Ohio Treasurer of State. 
   Include the Ohio IT 1140 UPC and write FEIN on check .....................................................AMOUNT DUE 888888888888
 If your refund is $1.00 or less, no refund will be issued. If you owe $1.00 or less, no payment is necessary.

Software vendors: Place 2D barcode in this location MM DD YY CODE
Do not place a box around the 2D barcode. The box
is only here for placement purposes. 2022 IT 1140 – pg.   of17

- 18 -

Enlarge image

2022 Ohio IT 1140
Rev. 07/25/22
22170210
FEIN
88 8888888
Sign Here (required): I have read this return. Under penalties of perjury, I declare that, to
the best of my knowledge and belief, the return and all enclosures are true, correct and complete. Do not staple or paper clip.
Place any supporting documents, including
Ohio IT K-1s, after the last page of this return.
Pass-through entity officer or agent (print)

Title of officer or agent (print) Phone number Mail to:
Signature of pass-through officer or agent Date (MM/DD/YY) Ohio Dept. of Taxation
P.O. Box 181140
Preparer’s name (print) Phone number Columbus, OH 43218-1140

Preparer’s e-mail address PTIN P 88888888
Instructions for this form are
Check here if you authorize your preparer to contact us regarding this return available at tax.ohio.gov.
X
If the amount on a line is negative, place a “–” in the box provided.
Schedule II – Qualifying Pass-Through Entities – Tax Due
Use this schedule to calculate the pass-through entity’s adjusted qualifying amount of business income and tax due before payments.
See instructions for all line item explanations found at tax.ohio.gov along with FAQs.
Column (A) – Withholding Tax Column (B) – Entity Tax
9. Qualifying investors’ distributive shares of income, gain,
expense and loss - 888888888888 - 888888888888

10. IRC §168(k) bonus depreciation and §179 expense and
Ohio authorized federal conformity add-back 888888888888 888888888888

10a. X 2/3, X 5/6 or X6/6 (check applicable box)
11. IRC §168(k) bonus depreciation and §179 expense
deductions from schedule V and Ohio authorized federal
conformity deductions (see instructions if filing as invest-
ment pass-through entity) 888888888888 888888888888

12. Sum of lines 9 and 10 minus line 11 - 888888888888 - 888888888888

13. Related members add-back (see instructions for complete
list of related members)
888888888888 888888888888

14. Guaranteed payments add-back (20% or greater investors
only) 888888888888 888888888888

15. Compensation add-back (20% or greater investors only)
888888888888 888888888888

Software vendors: Place 2D barcode in this location
Do not place a box around the 2D barcode. The box
is only here for placement purposes. 2022 IT 1140 – pg. of27

- 19 -

Enlarge image

                                                  2022 Ohio IT 1140
                             Rev. 07/25/22
                                                                                                                 22170310
FEIN
88 8888888
Schedule II – Qualifying Pass-Through Entities – Tax Due...continued.
                                                  Column (A) – Withholding Tax                                   Column (B) – Entity Tax
16.  Sum of lines 12, 13, 14 and 15 
    (if negative, enter “0”)                      888888888888                                                   888888888888

 17.  Apportionment ratio from line 24            8.888888                                                         8.888888

18. Adjusted qualifying amount (multiply 
 lines 16 and 17). If the sum of line 18 
 exceeds $1,000 continue to line 20               888888888888                                                   888888888888

19. Tax rate                                            X .05                                                      X .085
20. Tax due (multiply lines 18 and 19).
 Enter here and on the corresponding 
 column of line 1                                 888888888888                                                   888888888888

Schedule III – Qualifying Pass-Through Entities – Apportionment Worksheet
Calculate the apportionment ratio for a pass-through entity that is not a financial institution.  See instructions for calculation of financial institutions.  
Note: ratios must carry to six decimal places. 

  21.  Property                                   Within Ohio                                                    Total Everywhere
   a) Owned (original cost)                       888888888888                                                   888888888888
                                                  Within Ohio                                                    Total Everywhere
   b) Rented (annual rental X 8)                  888888888888                                                   888888888888
                                                  Within Ohio                                                    Total Everywhere
   c) Total (lines 21a and 21b)                   888888888888                 ÷                                 888888888888

                                                                  Ratio             Weight                         Weighted Ratio
                                                        =         8.888888       x  8.88                         = 8.888888
                                                  Within Ohio                                                    Total Everywhere
22.  Payroll                                      888888888888                 ÷                                 888888888888
                                                                  Ratio             Weight                         Weighted Ratio
                                                        =         8.888888       x  8.88                         = 8.888888
                                                  Within Ohio                                                    Total Everywhere
  23.  Sales                                      888888888888                 ÷                                 888888888888
                                                                  Ratio             Weight                         Weighted Ratio
                                                        =         8.888888       x  8.88                         = 8.888888

  24.  Ohio apportionment ratio (add lines 21c, 22 and 23). Enter ratio here and on line 17 above (both columns)   8.888888
Note: If the “Total Everywhere” of any factor is zero, the weight given to the other factors must be proportionately increased so that the total weight given 
to the combined number of factors used is 100%, i.e., if no property/payroll, use 25% and 75%; if no sales, use 50% property/payroll; if only one factor, 
use 100%.

                Software vendors: Place 2D barcode in this location
                Do not place a box around the 2D barcode. The box
                             is only here for placement purposes.              2022 IT 1140 – pg.   of37

- 20 -

Enlarge image

2022 Ohio IT 1140
Rev. 07/25/22
22170410
FEIN
88 8888888
Schedule IV – Trusts – Tax Due
Use this schedule to calculate the adjusted qualifying amount and tax due before payments for nonresident individual beneficiaries of a trust. See instruc-
tions for all line-item explanations found at tax.ohio.gov along with FAQs.

25. Sum of all distributions to nonresident individuals of income or gain attributable to the trust’s ownership
of or disposition of either tangible personal property located in Ohio or real property located in Ohio - 888888888888
26. IRC §168(k) bonus depreciation and §179 expense and Ohio authorized federal conformity
add-back 888888888888
26a. X 2/3 X 5/6 X 6/6
27. IRC §168(k) bonus depreciation and §179 expense deductions from Schedule V and Ohio
authorized federal conformity deductions 888888888888

28. Sum of line 25 and 26 minus line 27 - 888888888888
29. Tax rate X .05

30. Tax due: multiply lines 28 and 29. Enter here and on line 1, column A 888888888888

Schedule V – IRC §168K Bonus Depreciation and §179 Expense Add-Back Schedule
Use this schedule to report current year IRC §168K Bonus Depreciation and IRC §179 Expense add-back and deductions from prior years Ohio add-
backs. See instructions for calculation tables.
X Check the box if partial or full depreciation add-back has been waived.
31. Current year IRC §168(k) bonus depreciation and IRC §179 expense add-back
888888888888
32. Prior years Ohio add-back amount and applicable add-back ratio from Ohio filed returns
Column (A) – Amount Column (B) – Ratio

32a. Year Prior .....................................................888888888888 X 2/3 X 5/6 X 6/6

32b. 2 Years Prior ................................................888888888888 X 2/3 X 5/6 X 6/6

32c. 3 Years Prior ................................................888888888888 X 2/3 X 5/6 X 6/6

32d. 4 Years Prior ................................................888888888888 X 2/3 X 5/6 X 6/6

32e. 5 Years Prior ................................................888888888888 X 2/3 X 5/6 X 6/6
Schedule VI – Investor Information
First list the investors whose income is included on the return in order from highest to lowest ownership percentage. Then list all remaining investors from highest
to lowest ownership percentage. Use additional sheets, if necessary.

X Check here if the investor is included on the return.
SSN FEIN Percent of ownership 1140 Share of PTE tax credit
888 88 8888 88 8888888 8.8888 888888888
First name / entity M.I. Last name
JOHNXXXXXXXXXXX Q PUBLICXXXXXXXXXXXXXX
Address
8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
City State ZIP code
CITYXXXXXXXXXXXXXXXX OH 88888

Software vendors: Place 2D barcode in this location
Do not place a box around the 2D barcode. The box
is only here for placement purposes. 2022 IT 1140 – pg. of47

- 21 -

Enlarge image

                                      2022 Ohio IT 1140
                    Rev. 07/25/22
                                                                                              22170510
FEIN
88 8888888

Schedule VI – Investor Information...continued
X    Check here if the investor is included on the return.

SSN                              FEIN                                   Percent of ownership 1140 Share of PTE tax credit
888 88 8888                      88 8888888                             8.8888               888888888
First name / entity                                       M.I. Last name
JOHNXXXXXXXXXXX                                           Q    PUBLICXXXXXXXXXXXXXX
Address
8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
City                                                                    State ZIP code
CITYXXXXXXXXXXXXXXXX                                                    OH    88888

X    Check here if the investor is included on the return.
SSN                              FEIN                                   Percent of ownership 1140 Share of PTE tax credit
888 88 8888                      88 8888888                             8.8888               888888888
First name / entity                                       M.I. Last name
JOHNXXXXXXXXXXX                                           Q    PUBLICXXXXXXXXXXXXXX
Address
8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
City                                                                    State ZIP code
CITYXXXXXXXXXXXXXXXX                                                    OH    88888

X    Check here if the investor is included on the return.
SSN                              FEIN                                   Percent of ownership 1140 Share of PTE tax credit
888 88 8888                      88 8888888                             8.8888               888888888
First name / entity                                       M.I. Last name
JOHNXXXXXXXXXXX                                           Q    PUBLICXXXXXXXXXXXXXX
Address
8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
City                                                                    State ZIP code
CITYXXXXXXXXXXXXXXXX                                                    OH    88888

X    Check here if the investor is included on the return.
SSN                              FEIN                                   Percent of ownership 1140 Share of PTE tax credit
888 88 8888                      88 8888888                             8.8888               888888888
First name / entity                                       M.I. Last name
JOHNXXXXXXXXXXX                                           Q    PUBLICXXXXXXXXXXXXXX
Address
8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
City                                                                    State ZIP code
CITYXXXXXXXXXXXXXXXX                                                    OH    88888

       Software vendors: Place 2D barcode in this location
       Do not place a box around the 2D barcode. The box
                    is only here for placement purposes.                       2022 IT 1140 – pg.   of57

- 22 -

Enlarge image

                                      2022 Ohio IT 1140
                    Rev. 07/25/22
                                                                                              22170610

FEIN
88 8888888

Schedule VI – Investor Information...continued
X    Check here if the investor is included on the return.

SSN                              FEIN                                   Percent of ownership 1140 Share of PTE tax credit
888 88 8888                      88 8888888                             8.8888               888888888
First name / entity                                       M.I. Last name
JOHNXXXXXXXXXXX                                           Q    PUBLICXXXXXXXXXXXXXX
Address
8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
City                                                                    State ZIP code
CITYXXXXXXXXXXXXXXXX                                                    OH    88888

X    Check here if the investor is included on the return.
SSN                              FEIN                                   Percent of ownership 1140 Share of PTE tax credit
888 88 8888                      88 8888888                             8.8888               888888888
First name / entity                                       M.I. Last name
JOHNXXXXXXXXXXX                                           Q    PUBLICXXXXXXXXXXXXXX
Address
8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
City                                                                    State ZIP code
CITYXXXXXXXXXXXXXXXX                                                    OH    88888

X    Check here if the investor is included on the return.
SSN                              FEIN                                   Percent of ownership 1140 Share of PTE tax credit
888 88 8888                      88 8888888                             8.8888               888888888
First name / entity                                       M.I. Last name
JOHNXXXXXXXXXXX                                           Q    PUBLICXXXXXXXXXXXXXX
Address
8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
City                                                                    State ZIP code
CITYXXXXXXXXXXXXXXXX                                                    OH    88888

X    Check here if the investor is included on the return.
SSN                              FEIN                                   Percent of ownership 1140 Share of PTE tax credit
888 88 8888                      88 8888888                             8.8888               888888888
First name / entity                                       M.I. Last name
JOHNXXXXXXXXXXX                                           Q    PUBLICXXXXXXXXXXXXXX
Address
8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
City                                                                    State ZIP code
CITYXXXXXXXXXXXXXXXX                                                    OH    88888

       Software vendors: Place 2D barcode in this location
       Do not place a box around the 2D barcode. The box
                    is only here for placement purposes.                       2022 IT 1140 – pg.   of67

- 23 -

Enlarge image

                                      2022 Ohio IT 1140
                    Rev. 07/25/22
                                                                                              22170710

FEIN
88 8888888

Schedule VI – Investor Information...continued
X    Check here if the investor is included on the return.

SSN                              FEIN                                   Percent of ownership 1140 Share of PTE tax credit
888 88 8888                      88 8888888                             8.8888               888888888
First name / entity                                       M.I. Last name
JOHNXXXXXXXXXXX                                           Q    PUBLICXXXXXXXXXXXXXX
Address
8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
City                                                                    State ZIP code
CITYXXXXXXXXXXXXXXXX                                                    OH    88888

X    Check here if the investor is included on the return.
SSN                              FEIN                                   Percent of ownership 1140 Share of PTE tax credit
888 88 8888                      88 8888888                             8.8888               888888888
First name / entity                                       M.I. Last name
JOHNXXXXXXXXXXX                                           Q    PUBLICXXXXXXXXXXXXXX
Address
8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
City                                                                    State ZIP code
CITYXXXXXXXXXXXXXXXX                                                    OH    88888

X    Check here if the investor is included on the return.
SSN                              FEIN                                   Percent of ownership 1140 Share of PTE tax credit
888 88 8888                      88 8888888                             8.8888               888888888
First name / entity                                       M.I. Last name
JOHNXXXXXXXXXXX                                           Q    PUBLICXXXXXXXXXXXXXX
Address
8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
City                                                                    State ZIP code
CITYXXXXXXXXXXXXXXXX                                                    OH    88888

       Software vendors: Place 2D barcode in this location
       Do not place a box around the 2D barcode. The box
                    is only here for placement purposes.                       2022 IT 1140 – pg.   of77

PDF file checksum: 143267953

(Plugin #1/9.12/13.0)