Rev. 10/ /2306

Scan Specifications for the 

2023 Ohio IT 1040 Bundle

Important Note

The following document (2023 IT 1040 Bundle) contains grids for 
placement of information on this specific tax form. To accurately print, 
do not reduce the size, rotate or center this document. Doing so jeop-
ardizes the integrity of the grid. When printing from Adobe Reader, 
select “None” for “Page Scaling,” which is under “Page Handling.”

The 2023 IT 1040 Bundle test samples must be initially submitted 
by December 1, 2023 and approved no later than April 19, 2024. 

                        Ohio Department of Taxation

                        4485 Northland Ridge Blvd.

                        Columbus, OH 43229

                        tax.ohio.gov

                              General Information

1) Dimensions: 
  
  Target or Registration Marks - Circles - measuring 0.2”. 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. The IT 1040 and             
  Schedule of Adjustments share one combined 2D barcode. The Schedule of Business Income, Schedule of  
  Credits, Schedule of Dependents, IT WH, IT RC, IT RE, IT 10, IT NRC and IT/SD Waiver each have one individual
  2D barcode per form.

2) 1D barcode - The last two numbers of the 1D barcode represent the vendor number. Use the Ohio Depart-
ment of Taxation assigned 2 digit vendor number. If you have a question about your barcode assignment, e-mail 
the Forms Unit at Forms@tax.ohio.gov. See the chart provided at the bottom of page 2 for barcode numbering. 

   NOTE: The vendor number also serves as the fourth and fifth digits of the SSN 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 information
(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 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, date return was generated by the taxpayer, sequence 
numbers, and the 1D and 2D barcodes follow grid layout. See chart provided on the bottom of page 2 for 
correct sequence number for each page of the bundle.

6) Enter the date return was generated by the taxpayer in the following format: MM DD YY.  There is to be a space 
between the month, day, and year fields. Follow grid layout for placement.

7) Do not use commas or decimals in the variable data fields except where shown in specs.
8) For monetary lines, generate whole dollar values only. Monetary lines with no values are represented by only 
a carriage return in the 2D barcode and are blank on the printed form.
9) The possible negative fields for the IT-1040 return are lines 1, 3, and 20.  The possible negative fields for the IT-
BUS are lines 2, 3, 4, 6, 9, and 10. No other forms have possible negative fields. Do not hard-code negative signs. 

10) Provide guidance to customers regarding duplex printing that instructs them to print pages 1 and 2 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.

11) Generate the following message for customers: “Do not enclose other documentation 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.

12) There are no spaces between whole dollar numbers.

13) Any other documents generated from the software must include a 1D barcode identifying it as 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
14) If the taxpayer is claiming dependents on the IT 1040, they must file Schedule of Dependents. The Schedule 
of Dependents should be submitted with the IT 1040 income tax return; it should never be submitted by itself. 

15) The Business Income Schedule has 8 entity lines and the Schedule of Dependents has 15 dependent lines. 
Generate duplicate copies of page 2 when applicable to accommodate any additional entities / dependents. If income 
statements exceed the allotted amounts allowed on form IT WH, generate duplicate copies when applicable to 
accommodate any income statements. However,  in all duplicate page occurances, omit the standard 1D and 2D 
barcodes from the duplicate pages and include the 10211411 barcode indicated above.

16) When an amended IT 1040 is filed, include the IT RE (Reason of Explanation and Corrections), and the IT 
NOL if applicable. Note: NOL carryback should not be allowed on the current year return. Make sure that the IT 
RE barcode on this return includes your assigned vendor number. For example, if your last two digits of your 1D 
barcode are “05”, make sure that the last two digits of the IT RE barcode is “05” also. If a second page of the IT 
RE is generated, the 1D barcode for additional information, as referenced in number 13, must be used.

17) If the preparer files a paper return, form IT/SD Waiver must be included. Make sure that the IT/SD Waiver 
barcode on this return includes your assigned vendor number. For example, if your last two digits of your 1D 
barcode are “05”, make sure that the last two digits of the IT/SD Waiver barcode is “05” also.

18) For all balance due returns, generate the proper Ohio Universal Payment Coupon.

19) 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 corrections to this income 
tax return within [the software program name], then print and mail.”

                              2D Barcode Instructions

                                             General Information
● The Ohio IT 1040 bundle 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
● Optimal dpi level is 300 dpi. The minimum dpi level is 200 dpi
● The minimum error correction code level is 4

                                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

                                               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 listed in the schema must be represented 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
 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 (Long Forms)
  Header Version Number T1 <CR> 
  Developer Code 1111 <CR> 
  Jurisdiction OH <CR> 
  Description 2300 <CR> 
  Spec Version 0 <CR> 
  Form Version 1 <CR> 
  Date Generated 011824 <CR> 
  Line Item Specific Data IN <CR> 
  Line Item Specific Data IT40 <CR> 
  Line Item Specific Data 0 <CR> 
  Trailer *EOD* <CR>

 Examples of 2D Barcode Data Streams (OUPC)
  Form ID                                                          22299 <CR>
  Tax Type                                                         440 <CR>
  ID Type                                                          01 <CR>
  ID Number                                                        00000123456789 <CR>
  Reporting Period                                                 1223 <CR>
  Coupon Type                                                      54 <CR>
  School District Number                                           0000 <CR>
  First Three Letters of Primary Taxpayer’s SSN                    CIT <CR>
  Amount of Payment (including cents)                              12345678900 <CR>           
  Trailer                                                          *EOD* <CR>

                                            Submission Process
● Testing of Ohio IT 1040 bundle packets commences on October 31, 2023 
● The deadline for an initial submission of Ohio IT 1040 bundle test packets is December 1, 2023 
● The deadline for approval of Ohio IT 1040 bundle test packets is April 19, 2024
● Test packets may be submitted by email to Forms@tax.ohio.gov
● The email subject line must include the vendor number, product name, tax year and form number in 
    that order e.g. 12_ABCTax_ 23_1040
● Submissions must include:
    ○One                                                (1) full field sample in a PDF format
    ○ Seventeen (17) test scenarios for the Ohio IT 1040 bundle provided by the Ohio Department of 
      Taxation. These test scenarios can include the following return, schedules, documents and pay-
      ment coupons: Ohio IT 1040, Schedule of Adjustments, Schedule of Business Income, Schedule 
      of Credits, Schedule of Dependents, IT WH, IT RC, IT RE, OUPC, IT/SD Waiver and others de-
      pending on the scenario. Send only the forms that each scenario requires. Note: Make sure to 
      send in the correct OUPC if a scenario requires it.
    ○ Each test scenario must be in a separate PDF using the following naming convention: vendor 
      number, product name, tax year, form number, test number. Example: 12_ABCTax_23_1040_Test 1
●An   emailed confirmation is sent to the vendor indicating the packet was received
● Submissions missing any of the items above will be rejected

                                                Testing Process
● 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, formatted properly and aligned 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

                                                   Notifications
● Communications regarding submissions are sent from Forms@tax.ohio.gov to the vendor email 
    address(es) on file for the product
    ● Vendor contact information may be submitted by email to the address above.
● If forms are released prior to approval, vendors must include a visual indicator to alert the taxpayer 
    that the return cannot yet be filed.
●An   emailed confirmation is sent to the vendor indicating the packet was approved, at which point the 
    product is authorized to remove the visual indicator.
●An   email 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, 2024 vendors will be notified and required to submit revised 
    test packets.

2023 1D BARCODE ASSIGNMENT AND SEQUENCE NUMBER GUIDELINES

                    1D Barcode 1D Barcode 1D Barcode                   1D Barcode
                                                                                     Sequence Number
                    Digits 1&2 Digits 3&4 Digits 5&6                   Digits 7&8

                                          Page 1 = 01                                Page 1 = 1
1040                23         00                                      Vendor Number
                                          Page 2 = 02                                Page 2 = 2

Schedule of                               Page 1 = 03                                Page 1 = 3
                    23         00                                      Vendor Number 
Adjustments                               Page 2 = 04                                Page 2 = 4

Schedule of                               Page 1 = 01                                Page 1 = 5
                    23         26                                      Vendor Number 
Business Income                           Page 2 = 02                                Page 2 = 6

                                          Page 1 = 01                                Page 1 = 7
Schedule of Credits 23         28                                      Vendor Number 
                                          Page 2 = 02                                Page 2 = 8

Schedule of                               Page 1 = 01                                Page 1 = 9
                    23         23                                      Vendor Number 
Dependents                                Page 2 = 02                                        Page 2 = 10

Schedule of                               Page 1 = 01                                  Page 1 = 11
                    23         35                                      Vendor Number 
Withholding                               Page 2 = 02                                        Page 2 = 12

IT RE               23         27         Page 1 = 01                  Vendor Number N/A

IT 10               23         12         Page 1 = 01                  Vendor Number N/A

IT/SD Waiver        23         34         Page 1 = 01                  Vendor Number   N/A

IT RC               23         38         Page 1 = 01                  Vendor Number   N/A

IT NRC              23         40         Page 1 = 01                  Vendor Number   N/A

*Pages 2 and 3 of the IT NRC utilize the universal barcode of 10211411.

Grid Layout 

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                                                                 Do not staple or paper clip.
3
4                                                                                                                     2023 Ohio IT 1040 
5                                                                                                                     Individual Income Tax Return
                                                                                                                                                                                                                                      23000110
6                                                            12 15 24                                Use only black ink/UPPERCASE letters. Use whole dollars only.                                                                             Sequence No. 1
7

8                                                              X  AMENDED RETURN     - Check here and include Ohio IT RE.                      X NOL CARRYBACK - Check here and include Schedule IT NOL.
9                                                              
10                                                           Primary taxpayer's SSN (required)       If deceased          Spouse’s SSN (if filing jointly)                                                             If deceased  School district # 
11
12                                                             216 01 1234                                 X               417 01 1234                                                                                    X           2307

13                                                           First name                                                   M.I. Last name
14
                                                                                                                           Q  PUBLICA CDE-GHIJ'LMNOX
15                                                             JOHN BC'EF-HIJK
16                                                           Spouse's first name (if filing jointly)                      M.I. Last name
17                                                                                                                             PUBLICA CDE-GHIJ'LMNOX
                                                               JANEAB DE'GHI-K
18                                                                                                                         Q
19                                                           Address line 1 (number and street) or P.O. Box
20
21                                                             1234 CHERRY LANEABCDE&G-IJKLMN/PQRS
22                                                           Address line 2 (apartment number, suite number, etc.)
23
24                                                             1234 CHERRY LANEAB DE-GH&JKLMN/PQRS
25                                                           City                                                                              State        ZIP code                                                              Ohio county (first four letters)
                                                                                                                                                 OH                                                                               FRAN
26                                                             CITYA CDEFGHIJKLMNOX                                                                         12345
27
28                                                           Foreign country (if the mailing address is outside the U.S.)                      Foreign postal code
29
30                                                             JAPANABCDEFGH IJKLMO                                                              X8X8X8X
31                                                           Residency Status – Check only one for primary                *Indicate state         Filing Status – Check one (as reported on federal income tax return)
32                                                           X    Resident        X Part-year        X     Nonresident*      GA                   X Single, head of household or qualifying surviving spouse
33                                                                                  resident*
34                                                           Check only one for spouse (if filing jointly)                *Indicate state            Married filing jointly                  
35                                                                Resident          Part-year              Nonresident*                           X                                                                                    Spouse’s SSN
                                                             X                    X                  X                       NY
36                                                                                  resident*                                                     X Married filing separately                                                         216 01 1234
37
38                                                           Ohio Nonresident Statement – See instructions for required criteria
39                                                           X    Primary meets the five criteria for irrebuttable presumption as nonresident.    X Federal extension filers - check here.
40
41                                                           X    Spouse meets the five criteria for irrebuttable presumption as nonresident.     X If someone can claim you (or your spouse if filing jointly) as a 
42                                                                                                                                                   dependent, check here.
                                                              
43
44                                                             1. Federal adjusted gross income (federal 1040 or 1040-SR, line 11). Place a "-" in the box  
                                                                 if negative .......................................................................................................................................... -  ....1.     12345678901
45
46                                                            
                                                               2a. Additions – Ohio Schedule of Adjustments, line 11 (include schedule) ....................................................2a.                                       12345678901
47
                                                              
48                                                           2b. Deductions Ohio– Schedule of Adjustments, line 44 (  include schedule) .................................................2b.                                          12345678901
49
50                                                            
51                              Do not staple or paper clip.                                                                                                                                                            -             12345678901
                                                               3. Ohio adjusted gross income (line 1 plus line 2a minus line 2b). Place a "-" in the box if negative ..                                                    ....3.
52
                                                               4. Exemption amount (include Schedule of Dependents if applicable) ..............      .............................4.                                                                             12345
53                                                                 Number of exemptions including you and your spouse/dependents, if applicable:  12
54                                                            
                                                               5. Ohio income tax base (line 3 minus line 4; if negative, enter zero)...............................................................5.                                12345678901
55
56                                                            
                                                               6. Taxable business income – Ohio Schedule of Business Income, line 15 (include schedule) .....................6.                                                          123456789
57
58                                                             7. Taxable nonbusiness income (line 5 minus line 6; if negative, enter zero) ...................................................7.                                     12345678901
59
60
61                                                                      Software vendors: Place 2D barcode in this location
62                                                                                                                                                                                                                                            MM-DD-YY
                                                                        Do not place a box around the 2D barcode. The box 
63                                                                                is only here for placement purposes.
64                                                                                                                                                                                                                                2023 IT 1040 – page 1 of 2
65
66

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                                                                     2023 Ohio IT 1040 
5                                                                 Individual Income Tax Return
6  SSN:       216 01 1234                                                                                                                                                      23000210  Sequence No. 2

7    7a. Amount from line 7 on page 1  ....................................................................................................................7a.                 12345678901
8
9   
     8a. Nonbusiness income tax liability on line 7a (see instructions for tax tables)...........................................................8a.                           123456789
10
11  
     8b. Business income tax liability – Ohio Schedule of Business Income, line 16 (include schedule) ..........................8b.                                                     1234567
12
13
     8c. Income tax liability before credits (line 8a plus line 8b) ..........................................................................................8c.              123456789
14
15   9. Ohio nonrefundable credits – Ohio Schedule of Credits, line 38 (include schedule) ..............................................9.                                     123456789
16
17   10. Tax liability after nonrefundable credits (line 8c minus line 9; if negative, enter zero) ............................................10.                             123456789
18
19   11. Interest penalty on underpayment of estimated tax (include Ohio IT/SD 2210) ....................................................11.                                   123456789
20
21 12. Unpaid use tax (see instructions) ............................................................................................................................12.       123456789
22
23   13. Total Ohio tax liability before withholding or estimated payments (add lines 10, 11 and 12) ...............................13.                                        123456789
24
25   14. Ohio income tax withheld – Schedule of Ohio Withholding, part A, line 1 (include schedule and
       income statements) ..............................................................................................................................................14.    123456789
26
27 15. Estimated and extension payments, and credit carryforward from last year's return ..............................................15.                                     123456789
28
29   16. Refundable credits – Ohio Schedule of Credits, line 44 (include schedule) .........................................................16.                                123456789
30
31   17. Amended return only – amount previously paid with original and/or amended return .........................................17.                                         123456789
32
33   18. Total Ohio tax payments (add lines 14, 15, 16 and 17) ........................................................................................18.                     123456789
34
35   19. Amended return only – overpayment previously requested on original and/or amended return ..........................19.                                                123456789
36
37   20. Line 18 minus line 19. Place a "-" in the box if negative ................................................................................. -  ......20.              123456789
38            If line 20 is MORE THAN line 13, skip to line 24. OTHERWISE, continue to line 21.
39   21. Tax due (line 13 minus line 20). If line 20 is negative, ignore the "-" and add line 20 to line 13..............................21.                                   123456789
40
41  22. Interest due on late payment of tax (see instructions) ............................................................................................................22. 123456789
42  
43 23.TOTAL AMOUNT DUE             (line 21 plus line 22).    Include the Ohio Universal Payment 
       Coupon (OUPC) and make check payable to “Ohio Treasurer of State” .............................. AMOUNT DUE23.                                                         123456789
44
45   24. Overpayment (line 20 minus line 13) ......................................................................................................................24.         123456789
46
    
47   25. Original return only – portion of line 24 carried forward to next year’s tax liability .................................................25.                           123456789
48   26. Original return only – portion of line 24 you wish to donate:
49       a.  Wishes for Sick Children            b . Wildlife Species                 c.  Military Injury Relief
50
              1234                                         1234                             1234
51                                                                                                                                    Total ....26g.                           123456789
52         d.  Ohio History Fund      e.  Nature Preserves/Scenic Rivers              f.  Breast/Cervical Cancer
53
              1234                                         1234                             1234
54  27. REFUND (line 24 minus lines 25 and 26g) .............................................................................YOUR  REFUND27.                                  123456789
55                           I have read this return. Under penalties of perjury, I declare that, to the best of my knowledge                        If your refund is $1.00 or less, no refund will be issued. 
   Sign Here (required): 
56 and belief, the return and all enclosures are true, correct and complete.                                                                           If you owe $1.00 or less, no payment is necessary.
57 Primary signature                                                                 Phone number                                                             NO Payment Included  –Mail to:
58                                                                                                                                                             Ohio Department of Taxation
59  Spouse’s signature                                                       Date                                                                                              P.O. Box 2679
                                                                                                                                                              Columbus, OH  43270-2679
60 Preparer's printed name                                                            Phone number                                                             Payment Included  –Mail to:
61                                                                                                                                                             Ohio Department of Taxation
62                                                                                                                                                                             P.O. Box 2057
63            discuss this return           X                                         P     01234567
            X Authorize your preparer to              Non-paid preparer      PTIN:                                                                             Columbus, OH  43270-2057

64                                                                                                                                                             2023 IT 1040 – page 2 of 2
65
66

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                                                      2023 Ohio Schedule 
5                                                      of Adjustments
6                                                      Use only black ink. Use whole dollars only.                                                                             23000310
7                                                            Primary taxpayer’s SSN
8                                                                                                                                                                                      Sequence No. 3
   01 15 24                                                  216 01 0123
9
10                                                           Additions 
11                                (Only add the following amounts if they are not included on Ohio IT 1040, line 1)

12   1.  Non-Ohio state or local government interest and dividends ....................................................................................1.                      123456789
13
14   2.  Ohio pass-through entity taxes excluded from federal adjusted gross income .......................................................2.                                  123456789
15
      
16   3.  Taxes paid to another state or District of Columbia related to IRS notice 2020-75 .................................................3.                                 123456789
17
18   4.  529 plan funds used for non-qualified expenses .....................................................................................................4.                        123456
19
20   5.  Losses from sale or disposition of Ohio public obligations ......................................................................................5.                   123456789
21  
22   6.  Nonmedical withdrawals from a medical savings account ......................................................................................6.                        123456789
23  

24   7.  Reimbursement of expenses previously deducted on an Ohio income tax return ..................................................7.                                       123456789
25
26 Federal

27    8.  Internal Revenue Code 168(k) and 179 depreciation expense add-back ...............................................................8.                                 123456789
28
29   9.  Exempt federal interest and dividends subject to state taxation .............................................................................9.                       123456789
30
31  10.  Federal conformity additions .................................................................................................................................10.     123456789
32
33   11.  Total additions (add lines 1 through 10 ONLY). Enter here and on Ohio IT 1040, line 2a ........................ 11.                                                  12345678901
34
                                                             Deductions 
35                                (Only deduct the following amounts if they are included on Ohio IT 1040, line 1)
36
37       
    12.  Business income deduction – Ohio Schedule of Business Income, line 13 ..........................................................12.                                           123456
38
    
39  13.  Employee compensation earned in Ohio by residents of neighboring states ..........................................................13.                                 123456789
40
41  14.  Taxable refunds, credits, or offsets of state and local income taxes (federal 1040, Schedule 1, line 1) ...............14.                                            123456789
42
43  15.  Taxable Social Security benefits (federal 1040 and 1040-SR, line 6b) .................................................................15.                             123456789
44
    
45  16.  Certain railroad benefits ........................................................................................................................................16. 123456789
46
    17.  Interest income from Ohio public obligations and purchase obligations; gains from the 
47      disposition of Ohio public obligations; or income from a transfer agreement ........................................................17.                                123456789
48
49  18.  Amounts contributed to an Ohio county's individual development account program ............................................18.                                        123456789
50
51  19.  Amounts contributed to a STABLE account: Ohio's ABLE plan ............................................................................19.                             123456789
52  
    20.  Income earned in Ohio by a qualifying out-of-state business or employee for disaster  
53       work conducted during a disaster response period ...............................................................................................20.                   123456789
54
55  21.  Certain payments related to the East Palestine train derailment ..........................................................................21.                         123456789
56
57  22.  Ohio adoption grant program payments received from the Ohio Department of Job and Family Services ..........22.                                                       123456789
58
59 Federal

60  23.  Federal interest and dividends exempt from state taxation ...................................................................................23.                      123456789
61
62
63
64                                                                                             2023 Schedule of Adjustments – page 1 of 2
65
66

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                                                        2023 Ohio Schedule 
5                                                                  of Adjustments
                                                                                                                                                                                    23000410
6                                                                  Primary taxpayer’s SSN
                                                                                                                                                                                            Sequence No. 
7                                                                                                                                                                                                        4
8                                                                  216 01 0123

9    24.    Deduction of prior year 168(k) and 179 depreciation add-backs ..........................................................................24.                             123456789
10  
11   25.  Refund or reimbursements from the federal 1040, Schedule 1, line 8z for federal itemized deductions 
          claimed on a prior year return ..............................................................................................................................25.          123456789
12  
13   26.  Repayment of income reported in a prior year .....................................................................................................26.                     123456789
14
15   27.  Wage expense not deducted based on the federal work opportunity tax credit ...................................................27.                                         123456789
16
17   28.   Federal conformity deductions ...............................................................................................................................28.
18                                                                                                                                                                                  123456789
19 Uniformed Services

20    29.  Military pay received by Ohio residents while stationed outside Ohio ..................................................................29.                               123456789
21
22   30.  Compensation earned by nonresident military servicemembers and their civilian spouses ..................................30.                                               123456789
23
24   31.  Uniformed services retirement income .................................................................................................................31.                 123456789
25
26   32.  Military injury relief fund grants and veteran’s disability severance payments ...........................................................32.                             123456789
27
28    33.  Certain Ohio National Guard reimbursements and benefits .................................................................................33.                             123456789
29  
30 Education

31   34.  Amounts contributed to a 529 Plan ......................................................................................................................34.                       123456
32
    
33   35.  Pell/Ohio College Opportunity taxable grant amounts used to pay room and board ...........................................35.                                                     123456
34
35   36.  Ohio educator expenses in excess of federal deduction ......................................................................................36.                                   123
36
     37.  Income attributable to loan repayments by the Ohio Department of Higher Education under the rural 
37        practice incentive program ...................................................................................................................................37.                 12345
38
39   38.  Grant program payments made by the Ohio Department of Higher Education on behalf of adopted students ...38.                                                                       1234
40
41 Medical

42   39.   Disability benefits .................................................................................................................................................39. 123456789
43
44   40.  Survivor benefits ...................................................................................................................................................40.  123456789
45
46   41.  Unreimbursed medical and health care expenses (see instructions for worksheet; include a copy) .................41.                                                       123456789
47
48   42.  Medical savings account contributions/earnings (see instructions for worksheet; include a copy) ....................42.                                                   123456789
49
50   43.  Qualified organ donor expenses ..........................................................................................................................43.                      12345
51
52   44.  Total deductions (add lines 12 through 43 ONLY). Enter here and on Ohio IT 1040, line 2b............................44.                                                   12345678901
53
54
55
56
57
58
59
60
61
62
63
64                                                                                        2023 Schedule of Adjustments – page 2 of 2
65
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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                                                           2023 Ohio Schedule
5                                                            of Business Income
6                                                                                                                                                                                     23260110
                                                            Use only black ink/UPPERCASE letters.
7                                                                   Primary taxpayer’s SSN
8                                                                                                                                                                                             Sequence No. 5
    01 15 24                                                        216 01 0123
9
10   Enter all business income that you (and your spouse, if filing jointly) received during the tax year on this schedule. Enter only those amounts that are 
     included in your federal adjusted gross income. 
11                                                   Only one Schedule of Business Income should be used for each return filed. See R.C. 5747.01(B). 
     Use whole dollars only. 
12   Part 1 – Business Income
13
14   Note: Do not include amounts listed on the IRS schedules below that are nonbusiness income. 
15   See R.C. 5747.01(C). If the amount on a line is negative, place a “-“ in the box provided.
16
      1. Schedule B – Interest and Ordinary Dividends ........................................................................................................1.
17                                                                                                                                                                                    123456789
     
18
      2. Schedule C – Net Profit or Loss From Business (Sole Proprietorship) ......................................................                  -  ...2.
19                                                                                                                                                                                    123456789
     
20
      3. Schedule D – Capital Gains and Losses ....................................................................................................  -  ...3.
21                                                                                                                                                                                    123456789
     
22
      4. Schedule E – Supplemental Income and Loss...........................................................................................        -  ...4.
23                                                                                                                                                                                    123456789
24
      5. Guaranteed payments or compensation from a pass-through entity to a 20% or greater direct                
25
        or indirect owner ......................................................................................................................................................5.
26                                                                                                                                                                                    123456789
27
      6. Schedule F – Net Profit or Loss From Farming ..........................................................................................     -  ...6.
28                                                                                                                                                                                    123456789

29    7. Add-back of electing pass-through entity taxes paid on the Ohio form IT 4738 that qualify as business income ....7.                                                          123456789
30    8. Add-back of taxes paid to another state or the District of Columbia related to IRS notice 2020-75 that 
31      qualify as business income ......................................................................................................................................8.           123456789
32
33    9. Other business income or loss not reported above (e.g. form 4797 amounts) ..........................................                        -  ...9.                         123456789
34
35   10. Total business income (add lines 1 through 9) ...........................................................................................   -  .10.                          123456789
36
37  Part 2 – Business Income Deduction
38
     11. Enter the lesser of line 10 above or Ohio IT 1040, line 1. If negative, enter zero; 
39       stop here and do not complete Part 3 ...................................................................................................................11.                  123456789
40
     12. Enter $250,000 if filing status is single or married filing jointly; OR
41   
        Enter $125,000 if filing status is married filing separately ......................................................................................12.                                123456
42
43   13. Enter the lesser of line 11 or line 12. Enter here and on Ohio Schedule of Adjustments, line 12 .................................13.                                                 123456
44
45  Part 3 – Taxable Business Income

46   Note: If Ohio IT 1040, line 5 is zero, do not complete Part 3.
47   14. Line 11 minus line 13      ..............................................................................................................................................14. 123456789
48   15. Taxable business income (enter the lesser of line 14 above or Ohio IT 1040, line 5).   Enter here and 
49      on Ohio IT 1040, line 6 ...........................................................................................................................................15.        123456789
50   

51   16. Business income tax liability – multiply line 15 by 3% (.03). Enter here and on Ohio IT 1040, line 8b ......................16.                                              1234567
52
53
54
55
56
57                 Software vendors: Place 2D barcode in this location
58                 Do not place a box around the 2D barcode. The box
59                               is only here for placement purposes.
60
61
62
63
64                                                                                             2023 Schedule of Business Income – page 1 of 2
65
66

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                                   2023 Ohio Schedule
5                                    of Business Income
6                                                Primary taxpayer’s SSN                                        23260210
7
                                                 216 01 0123
8  Part 4 – Business Sources                                                                                           Sequence No. 6
9
   List all sources of business income, with Ohio sources listed first. Also separately list your ownership percentage and/or your spouse’s ownership percent-
10 age (if filing jointly). If necessary, complete additional copies of this page and include with your return.
11
12
13   1. FEIN / SSN           Primary ownership   Spouse’s ownership

14      123456789            050.00            % 050.00 %
15                           .                   .
16      Business name
17
18      QUICK-BROWNFOX&THE’COWJUMPEDTHE 3/4 MOON
19   2. FEIN / SSN           Primary ownership   Spouse’s ownership

20      123456789            050.00            % 050.00 %
21                           .                   .
22      Business name
23
24      QUICK-BROWNFOX&THE’COWJUMPEDTHE 3/4 MOON
25   3. FEIN / SSN           Primary ownership   Spouse’s ownership

26      123456789            050.00            % 050.00 %
27                           .                   .
28      Business name
29
30      QUICK-BROWNFOX&THE’COWJUMPEDTHE 3/4 MOON
31   4. FEIN / SSN           Primary ownership   Spouse’s ownership

32      123456789            050.00            % 050.00 %
33                           .                   .
34      Business name
35
36      QUICK-BROWNFOX&THE’COWJUMPEDTHE 3/4 MOON
37   5. FEIN / SSN           Primary ownership   Spouse’s ownership

38      123456789            050.00            % 050.00 %
39                           .                   .
40      Business name
41
42      QUICK-BROWNFOX&THE’COWJUMPEDTHE 3/4 MOON
43   6. FEIN / SSN           Primary ownership   Spouse’s ownership

44      123456789            050.00            % 050.00 %
45                           .                   .
46      Business name
47
48      QUICK-BROWNFOX&THE’COWJUMPEDTHE 3/4 MOON
49   7. FEIN / SSN           Primary ownership   Spouse’s ownership

50      123456789            050.00            % 050.00 %
51                           .                   .
52      Business name
53
54      QUICK-BROWNFOX&THE’COWJUMPEDTHE 3/4 MOON
55   8. FEIN / SSN           Primary ownership   Spouse’s ownership

56      123456789            050.00            % 050.00 %
57                           .                   .
58      Business name
59
60      QUICK-BROWNFOX&THE’COWJUMPEDTHE 3/4 MOON
61
62
63
64                                                                      2023 Schedule of Business Income – page 2 of 2
65
66

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                                                                            2023 Ohio Schedule of Credits
                                                                                  Use only black ink. Use whole dollars only.
5                                                                                                  Primary taxpayer’s SSN                                                          23280110
6                                                                                                                                                                                          Sequence No. 7
7    01 01 01                                                                                      123 45 6789
8          Many of these credits must be calculated using a worksheet and/or be supported by additional required documentation. See the instructions for 
9          worksheets and information on supporting documentation.
10
11                                                                                                 Nonrefundable Credits
12
13      1.  Tax liability before credits (from Ohio IT 1040, line 8c) ............................................................................................1.                       123456789

14      2.  Retirement income credit (include 1099-R forms) .................................................................................................2.
15                                                                                                                                                                                         123

16      3.  Lump sum retirement credit (include a copy of the worksheet and 1099-R forms) ..........................................3.
17                                                                                                                                                                                         123456
18
19      4.  Senior citizen credit (must be 65 or older to claim this credit) ...............................................................................4.                             12
20    
21      5.  Lump sum distribution credit (include a copy of the worksheet and 1099-R forms) .........................................5.                                                    1234

22      6.  Child care & dependent care credit (include a copy of the worksheet) ..............................................................6.
23                                                                                                                                                                                         1234
24
25      7.  Displaced worker training credit (include a copy of the worksheet and all required documentation) ................7.                                                           1234
26
27      8.  Campaign contribution credit for Ohio statewide office or General Assembly .......................................................8.                                           123

28      9.  Exemption credit ....................................................................................................................................................9.
29                                                                                                                                                                                         123
      
30     10.  Total (add lines 2 through 9) ................................................................................................................................10.
31                                                                                                                                                                                         123456789

32     11.  Tax less credits (line 1 minus line 10; if negative, enter zero) .............................................................................. 11.
33                                                                                                                                                                                         123456789
34    
35   12.   Joint filing credit (see instructions for table).               % times01line 11, up to $650    ..............................................................12.               123
36
37     13.  Earned income credit ...........................................................................................................................................13.            1234
38
39     14.  Home school expenses credit (include copies of all required documentation) ..............................................14.                                                   123
40
41     15.  Scholarship donation credit (include copies of all required documentation) ..................................................15.                                               1234

42     16.  Nonchartered, nonpublic school tuition credit (include copies of all required documentation) ......................16.
43                                                                                                                                                                                         1234
44
45     17.  Credit for work-based learning experiences (include a copy of the credit certificate) ....................................17.                                                  1234567
46
47     18.  Ohio adoption credit carryforward ........................................................................................................................18.                  1234567

48     19.  Nonrefundable job retention credit (include a copy of the credit certificate) ...................................................19.
49                                                                                                                                                                                         1234567
50
51     20.  Credit for eligible new employees in an enterprise zone (                              include a copy of the credit certificate) .................20.                          1234567

52      21.  Credit for the beginning farmers financial management program (include a copy of the credit certificate) ....21.
53                                                                                                                                                                                         1234567
54
55     22.  Welcome Home Ohio credit (include a copy of the credit certificate) .............................................................22.                                           1234567
56
       23.  Credit for sale/rental of agricultural assets to beginning farmers (                       include a copy of the credit certificate) .....23.                                  1234567
57
58
59
60
61                      Software vendors: Place 2D barcode in this location
                               Do not place a box around the 2D barcode. The box 
62    
63                                           is only here for placement purposes.
64                                                                                                                           2023 Schedule of Credits – page 1 of 2
65
66

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                                                   2023 Ohio Schedule of Credits
5                                                                 Primary taxpayer’s SSN
                                                                                                                                                                            23280210
6                                                                                                                                                                                   Sequence No. 8
                                                                     123 45 6789
7
8
9   24.  Grape production credit .......................................................................................................................................24.         1234567

10   25.  InvestOhio credit (include a copy of the credit certificate) ..............................................................................25.
11                                                                                                                                                                                  1234567

12   26.  Lead abatement credit (include a copy of the credit certificate) .....................................................................26.
13                                                                                                                                                                                  1234567

14   27.  Opportunity zone investment credit (include a copy of the credit certificate) .................................................27. 
15                                                                                                                                                                                  1234567
16  
17   28.  Technology investment credit carryforward (include a copy of the credit certificate) ......................................28.                                            1234567

18   29.  Enterprise zone day care & training credits (include a copy of the credit certificate) .....................................29.
19                                                                                                                                                                                  1234567
20   30.  Research & development credit (include a copy of the credit certificate) .......................................................30.
21                                                                                                                                                                                  1234567

22   31.  Nonrefundable Ohio historic preservation credit (include a copy of the credit certificate) ..............................31.
                                                                                                                                                                                    1234567
23
24   32.  Ohio low-income housing credit (include a copy of the credit certificate) .......................................................32.
25                                                                                                                                                                                  1234567
26    33.  Affordable single-family housing credit (include a copy of the credit certificate) ............................................33.
                                                                                                                                                                                    1234567
27
28   34.  Total (add lines 12 through 33) ............................................................................................................................34.
                                                                                                                                                                                    123456789
29
30   35.  Tax less additional credits (line 11 minus line 34; if negative, enter zero)............................................................35.
31                                                                                                                                                                                  123456789
32   Residency Credits
33  36.  Nonresident credit – Ohio IT NRC, line 20 (include a copy) ..............................................................................36.
                                                                                                                                                                                    123456789
34
35   37.  Resident credit – Ohio IT RC, line 7 (include a copy) ........................................................................................37.
                                                                                                                                                                                    123456789
36
37   38. Total nonrefundable credits (add lines 10, 34, 36 and 37; enter here and on Ohio IT 1040, line 9) ................38.
                                                                                                                                                                                    123456789
38
39                                                                   Refundable Credits
40
41   39.  Refundable Ohio historic preservation credit (include a copy of the credit certificate) ...................................39.
                                                                                                                                                                                    12345678
42
    
43   40.  Refundable job creation credit & job retention credit (include a copy of the credit certificate) ................................40.
                                                                                                                                                                                    12345678
44
45   41.  Pass-through entity credit (include a copy of all Ohio IT K-1s) ........................................................................41.
                                                                                                                                                                                    12345678
46
47   42.  Motion picture & Broadway theatrical production credit (include a copy of the credit certificate) ...................42.
                                                                                                                                                                                    12345678
48
    
49   43.  Venture capital credit (include a copy of the credit certificate) .......................................................................43.
                                                                                                                                                                                    12345678
50
    
51   44. Total refundable credits (add lines 39 through 43; enter here and on Ohio IT 1040, line 16) ...........................44.
                                                                                                                                                                                    123456789
52
53
54
55
56
57
58
59
60
61
62
63
64                                                                                                        2023 Schedule of Credits – page 2 of 2
65
66

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                         2023 Ohio Schedule 
5                           of Dependents
6                         Use only black ink/UPPERCASE letters.                                   23230110
7                              Primary taxpayer's SSN
8                                                                                                                                Sequence No. 9
   01 15 23
9                              216 01 0123
   Do not list the primary filer and/or spouse (if filing jointly) as dependents on this schedule. Use this schedule to claim dependents. If you have more 
10 than 15 dependents, complete additional copies of this schedule and include them with your income tax return. Abbreviate the “Dependent’s relationship to 
11 you” if necessary. 
12
13   1. Dependent’s SSN   Dependent's date of birth (MM-DD-YYYY)                                  Dependent’s relationship to you
14
15 867 53 0950            12 12 2015                                                              ITSMY OFFSPRING
16 Dependent’s first name M.I. Dependent's last name
17 AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI
18
19   2. Dependent’s SSN   Dependent's date of birth (MM-DD-YYYY)                                  Dependent’s relationship to you
20
   867 53 0950            12 12 2015                                                              ITSMY OFFSPRING
21
22 Dependent’s first name M.I. Dependent's last name
23 AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI
24
25   3. Dependent’s SSN   Dependent's date of birth (MM-DD-YYYY)                                  Dependent’s relationship to you
26
   867 53 0950            12 12 2015                                                              ITSMY OFFSPRING
27
28 Dependent’s first name M.I. Dependent's last name
29                             PRS-UVWXYZ ABCD'FGHI
   AB-DEFGH IJ'LMN        Q
30
31   4. Dependent’s SSN   Dependent's date of birth (MM-DD-YYYY)                                  Dependent’s relationship to you
32
   867 53 0950            12 12 2015                                                              ITSMY OFFSPRING
33
34 Dependent’s first name M.I. Dependent's last name
35                             PRS-UVWXYZ ABCD'FGHI
   AB-DEFGH IJ'LMN        Q
36
37   5. Dependent’s SSN   Dependent's date of birth (MM-DD-YYYY)                                  Dependent’s relationship to you
38
   867 53 0950            12 12 2015                                                              ITSMY OFFSPRING
39
40 Dependent’s first name M.I. Dependent's last name
41                             PRS-UVWXYZ ABCD'FGHI
   AB-DEFGH IJ'LMN        Q
42
43   6. Dependent’s SSN   Dependent's date of birth (MM-DD-YYYY)                                  Dependent’s relationship to you
44
   867 53 0950            12 12 2015                                                              ITSMY OFFSPRING
45
46 Dependent’s first name M.I. Dependent's last name
47                             PRS-UVWXYZ ABCD'FGHI
   AB-DEFGH IJ'LMN        Q
48
49   7. Dependent’s SSN   Dependent's date of birth (MM-DD-YYYY)                                  Dependent’s relationship to you
50
   867 53 0950            12 12 2015                                                              ITSMY OFFSPRING
51
52 Dependent’s first name M.I. Dependent's last name 
53                             PRS-UVWXYZ ABCD'FGHI
   AB-DEFGH IJ'LMN        Q
54
55
56
57
58 Software vendors: Place 2D barcode in this location
59 Do not place a box around the 2D barcode. The box
60                      is only here for placement purposes.
61
62
63
64                                                                                                2023 Schedule of Dependents – page 1 of 2
65
66

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                         2023 Ohio Schedule 
5                           of Dependents 
6                                                                23230210
7                              Primary taxpayer's SSN
8                                                                                                Sequence No. 10
9                              216 01 0123
10   8. Dependent’s SSN   Dependent's date of birth (MM-DD-YYYY) Dependent’s relationship to you
11
12 867 53 0950            12 12 2015                             ITSMY OFFSPRING
13 Dependent’s first name M.I. Dependent's last name
14 AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI
15
16   9. Dependent’s SSN   Dependent's date of birth (MM-DD-YYYY) Dependent’s relationship to you
17
18 867 53 0950            12 12 2015                             ITSMY OFFSPRING
19 Dependent’s first name M.I. Dependent's last name
20 AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI
21
22   10. Dependent’s SSN  Dependent's date of birth (MM-DD-YYYY) Dependent’s relationship to you 
23
24 867 53 0950            12 12 2015                             ITSMY OFFSPRING
25 Dependent’s first name M.I. Dependent's last name
26 AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI
27
28   11. Dependent’s SSN  Dependent's date of birth (MM-DD-YYYY) Dependent’s relationship to you
29
30 867 53 0950            12 12 2015                             ITSMY OFFSPRING
31 Dependent’s first name M.I. Dependent's last name
32 AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI
33
34   12. Dependent’s SSN  Dependent's date of birth (MM-DD-YYYY) Dependent’s relationship to you
35
36 867 53 0950            12 12 2015                             ITSMY OFFSPRING
37 Dependent’s first name M.I. Dependent's last name
38 AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI
39
40   13. Dependent’s SSN  Dependent's date of birth (MM-DD-YYYY) Dependent’s relationship to you
41
42 867 53 0950            12 12 2015                             ITSMY OFFSPRING
43 Dependent’s first name M.I. Dependent's last name
44 AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI
45
46   14. Dependent’s SSN  Dependent's date of birth (MM-DD-YYYY) Dependent’s relationship to you
47
48 867 53 0950            12 12 2015                             ITSMY OFFSPRING
49 Dependent’s first name M.I. Dependent's last name
50                             PRS-UVWXYZ ABCD'FGHI
   AB-DEFGH IJ'LMN        Q
51
52 15. Dependent’s SSN    Dependent's date of birth (MM-DD-YYYY) Dependent’s relationship to you
53
54 867 53 0950            12 12 2015                             ITSMY OFFSPRING
55 Dependent’s first name M.I. Dependent's last name
56                             PRS-UVWXYZ ABCD'FGHI
   AB-DEFGH IJ'LMN        Q
57
58
59
60
61
62
63
64                                                               2023 Schedule of Dependents – page 2 of 2
65
66

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                                              2023 Schedule of Ohio 
5                                                                      Withholding 
                               Use only black ink/UPPERCASE letters. Use whole dollars only.                                                                23350110
6
7                                                                      Primary taxpayer’s SSN                                                                        Sequence No. 11
8
                                                                       216 01 0123
9
     List your and your spouse’s (if filing jointly) income statements only if they have Ohio withholding. In the “P/S” box, if the income statement belongs to the 
10   primary taxpayer, enter “P”; if the income statement belongs to the spouse, enter “S”. If the Ohio ID number on a statement has 9 digits, enter only the first 
11   8 digits. Complete additional copies of this schedule if necessary. Include state copies of your income statements.
12
13   Part A - Total Withholding
     1. Total of all Ohio state tax withheld on pages 1 and 2 as well as any additional pages. Enter here 
14     and on line 14 of your Ohio IT 1040 ..............................................................................................................1. 123456789
15
16   Part B - W-2s
17   1. P/S Box b - EIN                        Box 1 - Wages, tips, other compensation                    Box 2 - Federal income tax withheld
18
        P   123456789                          123456789                                                  12345678
19
20          Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc.                                                                              Box 17 - Ohio income tax
21
22          12345678                           123456789                                                                                                    12345678
23   2. P/S Box b - EIN                        Box 1 - Wages, tips, other compensation                    Box 2 - Federal income tax withheld
24
        S   123456789                          123456789                                                  12345678
25
26          Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc.                                                                              Box 17 - Ohio income tax
27
            12345678
28                                             123456789                                                                                                    12345678
29   3. P/S Box b - EIN                        Box 1 - Wages, tips, other compensation                    Box 2 - Federal income tax withheld
            123456789                          123456789
30      P                                                                                                 12345678
31
32          Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc.                                                                              Box 17 - Ohio income tax
33
            12345678                           123456789                                                                                                    12345678
34
35   4. P/S Box b - EIN                        Box 1 - Wages, tips, other compensation                    Box 2 - Federal income tax withheld
            123456789                          123456789
36      S                                                                                                 12345678
37
38          Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc.                                                                              Box 17 - Ohio income tax
39
            12345678                           123456789                                                                                                    12345678
40
41   5. P/S Box b - EIN                        Box 1 - Wages, tips, other compensation                    Box 2 - Federal income tax withheld
            123456789                          123456789
42      P                                                                                                 12345678
43
     
44          Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc.                                                                              Box 17 - Ohio income tax
45
            12345678                           123456789                                                                                                    12345678
46
47   6. P/S Box b - EIN                        Box 1 - Wages, tips, other compensation                    Box 2 - Federal income tax withheld
            123456789                          123456789
48      S                                                                                                 12345678
49
50          Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc.                                                                              Box 17 - Ohio income tax
51
            12345678                           123456789                                                                                                    12345678
52
53   7. P/S Box b - EIN                        Box 1 - Wages, tips, other compensation                    Box 2 - Federal income tax withheld
            123456789                          123456789
54      P                                                                                                 12345678
55
56          Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc.                                                                              Box 17 - Ohio income tax
57
            12345678                           123456789                                                                                                    12345678
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.
64                                                                                                        2023 Schedule of Withholding – page 1 of 2
65
66

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                                         2023 Schedule of Ohio 
5                                         Withholding 
                                          Primary taxpayer’s SSN                             23350210
6
7    Part C - 1099-Rs                         216 01 0123                                            Sequence No. 12
8    1. P/S Payer’s TIN                   Box 1 - Gross distribution
9                                                                             Total          Box 7 -
        S   123456789                     123456789                           distribution   Distribution code
10                                                                                         X                           X8
11          Box 15 - Payer’s Ohio number  Box 4 - Federal income tax withheld              Box 14 - Ohio tax withheld
12
            12345678
13                                        123456789                                        12345678
14   2. P/S Payer’s TIN                   Box 1 - Gross distribution
15                                                                            Total          Box 7 -
                                                                              distribution   Distribution code
16      P   123456789                     123456789                                        X                           X8
17          Box 15 - Payer’s Ohio number  Box 4 - Federal income tax withheld              Box 14 - Ohio tax withheld
18
19          12345678                      123456789                                        12345678
20   3. P/S Payer’s TIN                   Box 1 - Gross distribution
21                                                                            Total          Box 7 -
                                                                              distribution   Distribution code
22      S   123456789                     123456789                                        X                           X8
23          Box 15 - Payer’s Ohio number  Box 4 - Federal income tax withheld              Box 14 - Ohio tax withheld
24
25          12345678                      123456789                                        12345678
26   4. P/S Payer’s TIN                   Box 1 - Gross distribution
27                                                                            Total          Box 7 -
                                                                              distribution   Distribution code
28      P   123456789                     123456789                                        X                           X8
29          Box 15 - Payer’s Ohio number  Box 4 - Federal income tax withheld              Box 14 - Ohio tax withheld
30
31          12345678                      123456789                                        12345678
32   Part D - W-2Gs
33   1. P/S Payer’s federal ID number     Box 1 - Reportable winnings               Box 4 - Federal income tax withheld
34
35      S   123456789                     123456789                                 12345678
     
36          Box 13 - Ohio state ID number Box 14 - Ohio state winnings                     Box 15 - Ohio income tax withheld
37
38          12345678                      123456789                                        12345678
39   2. P/S Payer’s federal ID number     Box 1 - Reportable winnings               Box 4 - Federal income tax withheld
40
41      P   123456789                     123456789                                 12345678
42          Box 13 - Ohio state ID number Box 14 - Ohio state winnings                     Box 15 - Ohio income tax withheld
43
44          12345678                      123456789                                        12345678
45   3. P/S Payer’s federal ID number     Box 1 - Reportable winnings               Box 4 - Federal income tax withheld
46
47      S   123456789                     123456789                                 12345678
48          Box 13 - Ohio state ID number Box 14 - Ohio state winnings                     Box 15 - Ohio income tax withheld
49
50          12345678                      123456789                                        12345678
51   Part E - 1099-NECs
52   1. P/S Payer’s TIN                   Box 1 - Nonemployee compensation          Box 4 - Federal income tax withheld
            123456789                     123456789
53      P                                                                           12345678
54
55          Box 6 - Payer’s Ohio number   Box 7 - State income                             Box 5 - Ohio tax withheld
56
            12345678                      123456789                                        12345678
57
58   2. P/S Payer’s TIN                   Box 1 - Nonemployee compensation          Box 4 - Federal income tax withheld
            123456789                     123456789
59      S                                                                           12345678
60
61          Box 6 - Payer’s Ohio number   Box 7 - State income                             Box 5 - Ohio tax withheld
62
            12345678                      123456789                                        12345678
63
64                                                                            2023 Schedule of Withholding – page 2 of 2
65
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2
3
4                                                         2023 Ohio IT RE 
5                                                         Explanation of Corrections
                                                                                                                                  23270110
6                                                  Note: For amended individual return only
7
                                                          Primary taxpayer's SSN
8
9
                                                          216 01 0123
10
11 Complete the Ohio IT 1040 and indicate that it is amended by checking the box at the top of page 1. You must include this form and 
12 documentation to support the adjustments on your amended return. 
13
   Reason(s):
14
15 X Federal adjusted gross income decreased                        X     Filing status changed
16
17 X Exemptions increased (include Schedule of Dependents)
18
19 If you checked any of the boxes above,          do not file your Ohio amended return until the IRS has accepted the changes on your federal 
20 amended return. 
21
22
23
     Federal adjusted gross income increased                          Ohio Schedule of Credits, nonresident credit increased
24 X                                                                X
25
     Exemptions decreased (include Schedule of Dependents)            Ohio Schedule of Credits, nonresident credit decreased 
26 X                                                                X
27
     Residency status changed                                         Ohio Schedule of Credits, resident credit increased
28 X                                                                X
29
     Ohio Schedule of Adjustments, additions to income                Ohio Schedule of Credits, resident credit decreased
30 X                                                                X
31
     Ohio Schedule of Adjustments, deductions from income             Ohio Schedule of Credits, refundable credit(s) increased
32 X                                                                X
33
     Ohio Schedule of Credits, nonrefundable credit(s) increased      Ohio Schedule of Credits, refundable credit(s) decreased
34 X                                                                X
35
     Ohio Schedule of Credits, nonrefundable credit(s) decreased      Other (describe the reason below)
36 X                                                                X
37
38 Note: Include any worksheets and/or documentation necessary to support your changes. See the filing tips on the next page as well as 
39 the Ohio Individual and School District income tax instructions. 
40
   Detailed explanation of adjusted items (include additional sheet[s] if necessary):
41
42
43 ABCDEFGHIJKLMNOPQRSTUVWXYZABCDEFGHIJKLMNOPQRSTUVWXYZABCDEFGHIJKLMNOPQRS
44 ABCDEFGHIJKLMNOPQRSTUVWXYZABCDEFGHIJKLMNOPQRSTUVWXYZABCDEFGHIJKLMNOPQRS
45 ABCDEFGHIJKLMNOPQRSTUVWXYZABCDEFGHIJKLMNOPQRSTUVWXYZABCDEFGHIJKLMNOPQRS
46 ABCDEFGHIJKLMNOPQRSTUVWXYZABCDEFGHIJKLMNOPQRSTUVWXYZABCDEFGHIJKLMNOPQRS
47 ABCDEFGHIJKLMNOPQRSTUVWXYZABCDEFGHIJKLMNOPQRSTUVWXYZABCDEFGHIJKLMNOPQRS
48 ABCDEFGHIJKLMNOPQRSTUVWXYZABCDEFGHIJKLMNOPQRSTUVWXYZABCDEFGHIJKLMNOPQRS
49 ABCDEFGHIJKLMNOPQRSTUVWXYZABCDEFGHIJKLMNOPQRSTUVWXYZABCDEFGHIJKLMNOPQRS
50 ABCDEFGHIJKLMNOPQRSTUVWXYZABCDEFGHIJKLMNOPQRSTUVWXYZABCDEFGHIJKLMNOPQRS
51
52 E-mail address                                                    Telephone number
53
54 Federal Privacy Act Notice: Because we require you to provide us with a Social Security number, the Federal Privacy Act of 1974 requires us to inform you that providing us 
   with your Social Security number is mandatory. Ohio Revised Code sections 5703.05, 5703.057 and 5747.08 authorize us to request this information. We need your Social 
55 Security number in order to administer this tax.
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.
64                                                                                                                                2023 IT RE – page 1 of 2
65
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2
3
                                                            2023 IT RC
4                                    Ohio Resident Credit Calculation
5                                    Use black ink only. Use whole dollars only.
6                                       Primary taxpayer’s SSN                                                                                       23380110
7
8                                                           216 01 0123
9  This form is for individuals who were subjected to individual income tax by another state or the District of Columbia while a resident of 
10 Ohio. Full-year nonresidents are not entitled to this credit and should not use this form. Include a copy when filing your Ohio IT 1040. 
11 List any income taxed and any taxes paid to each state and/or the District of Columbia. Do not include income earned or received in states 
12 without an income tax. Only income included in your Ohio adjusted gross income is eligible for this credit. Important: Do not list any in-
13 come in Column A if you do not have tax paid in Column B. Do not list a tax paid in Column B if you do not have income taxed in Column A.
14
15    (A)                        (B)                        (A)        (B)                                                                           (A)          (B)
16    Income Taxed         Tax Paid     Income Taxed            Tax Paid                                                                             Income Taxed Tax Paid
17
18 AL                                KS                                                         NH
      123456789  123456789              123456789               123456789                                                                            123456789  123456789 
19
20 AR                                KY                                                         NJ
21    123456789  123456789              123456789               123456789                                                                            123456789  123456789 
22 AZ                                LA                                                         NM
      123456789  123456789              123456789               123456789                                                                            123456789  123456789 
23
24 CA                                MA                                                         NY
      123456789  123456789              123456789               123456789                                                                            123456789  123456789 
25
26 CO                                MD                                                         OK
      123456789  123456789              123456789               123456789                                                                            123456789  123456789 
27
28 CT                                ME                                                         OR
      123456789  123456789              123456789               123456789                                                                            123456789  123456789 
29
30 DC                                MI                                                         PA
      123456789  123456789              123456789               123456789                                                                            123456789  123456789 
31
32 DE                                MN                                                         RI
      123456789  123456789              123456789               123456789                                                                            123456789  123456789 
33
34 GA                                MO                                                         SC
35    123456789  123456789              123456789               123456789                                                                            123456789  123456789 

36 HI                                MS                                                         UT
37    123456789  123456789              123456789               123456789                                                                            123456789  123456789 
38 IA                                MT                                                         VA
      123456789  123456789              123456789               123456789                                                                            123456789  123456789 
39
40 ID                                NC                                                         VT
      123456789  123456789              123456789               123456789                                                                            123456789  123456789 
41
42 IL                                ND                                                         WI
43    123456789  123456789              123456789               123456789                                                                            123456789  123456789 

44 IN                                NE                                                         WV
45    123456789  123456789              123456789               123456789                                                                            123456789  123456789 
46
47 1. Sum of all Column A amounts ....................................................................................................1.
                                                                                                                                                         12345678901 
48
49 2. Sum of all Column B amounts ....................................................................................................2.
                                                                                                                                                                  123456789
50
51 3. Ohio adjusted gross income (from Ohio IT 1040, line 3) ............................................................3.
                                                                                                                                                         12345678901
52
53 4. Divide line 1 by line 3. Carry to four digits without rounding. If greater than 1, enter 1 ..............4.
                                                                                                                                                                  0.1234
54 5. Ohio Schedule of Credits, line 35 minus Ohio Schedule of Credits, line 36. If negative, 
55   enter zero ...................................................................................................................................5.
                                                                                                                                                                  123456789
56
57 6. Multiply line 4 by line 5 ...............................................................................................................6.
                                                                                                                                                                  123456789
58 7. Ohio Resident Credit. Enter the lesser of line 2 or line 6. Enter here and on the Ohio 
59   Schedule of Credits, line 37 .......................................................................................................7.                       123456789
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.
64                                                                                                                                                   2023 IT RC – page 1 of 1
65
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2
3         Do not staple or paper clip.
4                                                                       2023 Ohio IT 10 
5                                                                       Zero Liability / No Refund 
6                                                                   Individual Income Tax Return
7                                                               Use only black ink and UPPERCASE letters.                                 23120110
   01 15 24
8  Important: You can only file an IT 1040 or an IT 10. If you are liable for school district income tax, you must file the Ohio IT 1040.
9
10 Primary taxpayer's SSN (required)         If deceased                Spouse’s SSN (if filing jointly)          If deceased          School district # 
11
12   216 01 0123                                       X                  417 01 0123                                   X                 0905
13 First name                                                           M.I. Last name
14
15   JOHN BC’EF-HIJK                                                     Q  PUBLICA CDE-GHIJ’LMNOP
16 Spouse's first name (only if married filing jointly)                 M.I. Last name
17
18   JANEAB DE’GHI-K                                                     Q   PUBLICA CDE-GHIJ’LMNOP

19 Address line 1 (number and street) or P.O. Box
20
21   5123 CHERRY LANEABCDE&G-IJKLMNOP/RS
22 Address line 2 (apartment number, suite number, etc.)
23
24   5123 CHERRY LANEAB DE-GH&JKLMNOP/RS                          
25 City                                                                                    State          ZIP code         Ohio county (first four letters)
26
27   CITYA CDEFGHIJKLMNOX                                                                  OH             45318            FRAN
28 Foreign country (if the mailing address is outside the U.S.)                            Foreign postal code
29
30   JAPANABCDE GHJIJKLMO                                                                  X8X8X8X
31 Residency Status – Check only one for primary                        *Indicate state    Filing Status – Check one (as reported on federal income tax return)
32      Resident            Part-year                  Nonresident*                              Single, head of household or qualifying surviving spouse
33 X                    X   resident*        X                               GA            X
34 Check only one for spouse (if filing jointly)                        *Indicate state          Married filing jointly                  
                                                                                           X
35 X    Resident        X   Part-year        X         Nonresident*          NY                                                           Spouse’s SSN
36                          resident*                                                             Married filing separately
37                                                                                         X                                             417 01 0123
38 Ohio Nonresident Statement – See instructions for required criteria
39 X    Primary meets the five criteria for irrebuttable presumption as nonresident.       X Federal extension filers - check here.
40
41      Spouse meets the five criteria for irrebuttable presumption as nonresident.
42 X
43 Reason(s) For Filing (Required): By filing this return, the primary taxpayer and spouse (if filing jointly) declare that their correctly calculated tax liability 
44 (Ohio IT 1040, line 8c) is $0.00 for one or more of the following reasons (check all that apply):
45      There is no tax liability on my Ohio taxable nonbusiness income                  X I was a nonresident military servicemember for the entire tax year  
46  X   (Ohio IT 1040, line 7) and taxable business income (Ohio IT 1040, line 6).         and my only source of income earned in Ohio is from the military.

47 X    I was a nonresident of Ohio for the entire tax year and did not have             X I was a civilian spouse of a nonresident servicemember stationed in  
48      Ohio-sourced income (e.g. the above address is for mailing purposes only).         Ohio.
49 I understand that I cannot request a refund of any amount on this return.
50
51 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.
52
   Primary signature                                                               Phone number                                         Mail to:
53                                                                                       
54 Spouse’s signature                                                              Date                                   Ohio Department of Taxation
55 Preparer's printed name                                                          Phone number                                         P.O. Box 2476
56
57                                                                                                                         Columbus, OH 43216-2476
58            discuss this return            X                                      P    01234567
          X Authorize your preparer to             Non-paid preparer         PTIN:
59
60
61        Software vendors: Place 2D barcode in this location
62        Do not place a box around the 2D barcode. The box                                                                                          MM-DD-YY
63                  is only here for placement purposes.
64                                                                                                                                       2023 IT 10 - page 1 of 1 
65
66

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2
3
4
5                                                   2023 IT/SD Waiver
6                                                  Individual Waiver from the Income Tax                                          23340110
7                                                  Return Electronic Filing Requirement
8
9
10 Paid preparers who prepare more than 11 Ohio income tax returns for the calendar year must electronically file all returns. 
11 If you use a paid preparer but you are unwilling or unable to file electronically, you must include a copy of this form 
12 when filing your Ohio income tax return by paper.
13
14
15 Part I – To be completed by the taxpayer
16 Taxpayer SSN                                    Taxpayer Name
17
18      216 01 1234                                ABCDEFGHIJKLMNOPQRSTUVWX
19 Spouse’s SSN (if filing jointly)                Spouse’s Name (if filing jointly)
20
21      419 12 3456                                ABCDEFGHIJKLMNOPQRSTUVWX
22 By signing below, I acknowledge that I do not want to, or my preparer cannot, electronically file my Ohio income tax return.
23
24
25
   Taxpayer signature                                           Spouse’s signature (if filing jointly)
26
27
28
29
30 Part II – To be completed by the preparer
31 Business Name                                                                                             FEIN
32
33  ABC-EFGH/JKLM& ORSTU’WXYZA                                                                               21 5874632
34 Business Address
35
36  ABCD-FGHI&KLMN/P RSTUVWXYZABCD
37 City                                                                                                State                      Zip Code
38
    CITYABC EFGHIJKLMNOP                                                                               OH                         45698
39
40 Preparer Name                                                                                             PTIN
41
    ABC-EFGH/JKLM& ORSTU’WXYZA                                                                               P 58745698
42
43 Reason (check at least one)
44      Taxpayer opts not to file electronically
    
45  X
46      Taxpayer is a victim of identity theft
47  X
48      Taxpayer cannot file electronically; 
49  X   MEF rejection error code (if applicable):
50                                                  ABCDE5GHIJ8LM427RS
51
52
53
   Federal Privacy Act Notice: Because we require you to provide us with a Social Security number, the Federal Privacy Act of 1974 requires us to inform you that providing us 
54 with your Social Security number is mandatory. Ohio Revised Code sections 5703.05, 5703.057 and 5747.08 authorize us to request this information. We need your Social 
55 Security number in order to administer this tax.
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.
64                                                                                                               2023 IT/SD Waiver - page 1 of 1
65
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2
3
4                                                2023 IT NRC
                                                 Ohio Nonresident Credit Calculation
5                                                Use black ink only. Use whole dollars only.
6                                                Primary taxpayer's SSN                                                                          23400110
7
8                                                216 01 0123
9  This form is for individuals who were either full-year nonresidents or part-year residents of Ohio during the tax year above. Generally, 
10 full-year residents of Ohio should not complete this form. However, full-year Ohio residents filing a joint return with a nonresident or part-
11 year resident spouse should include all their income in Column B. Part-year residents should enter their dates of residency below.
12
13 Primary taxpayer’s dates of Ohio residency                Spouse’s dates of Ohio residency (if filing jointly)
14                         to                                                                                     to
15 01 01 23                      05 01 23                    01 01 23                                                                            05 01 23
16
17
   Section I – Nonresident Credit Calculation
18
   For each line in this section, enter in Column A the total income included on your federal return. Enter in Column B income earned or 
19 received in Ohio from each of the corresponding sources. Only report amounts included in federal adjusted gross income.
20
21 Part A - Complete for taxpayers who are either part-year or full-year nonresidents of Ohio.
22
23                                                                                                                                           (A)                (B)
24  1.  Wages, salaries, tips, and guaranteed payments (Do not include amounts                                    Federal Amount                                Ohio Amount
          paid  by a pass-through entity in which the taxpayer has a 20% or 
25
         greater direct or indirect ownership interest. See instructions) ...........................1. 
26                                                                                                                12345678901                                   12345678901 
     2. Nonbusiness capital gain income........................................................................2.
27                                                                                                                12345678901                                   12345678901 
     3. Nonbusiness rent and royalty income .................................................................3.
28                                                                                                                12345678901                                   12345678901 
     4. Lottery, casino, and sports gaming winnings ......................................................4.  
29                                                                                                                12345678901                                   12345678901 
     5. Business income (from Section II) ....................................................................................................................5.
30                                                                                                                                                              12345678901 
     6. Net Apportioned Ohio Depreciation Adjustment (from Section II, Line 22, Column B) .....................................6.
31                                                                                                                                                              12345678901 
32   7. Net additions from Ohio Schedule of Adjustments (excluding the IRC 168(k) & 179 depreciation add-back)
       List the additions here:__________________________________________________________ ..................7.
33                                                                                                                                                              12345678901 
34   8. Net deductions from Ohio Schedule of Adjustments (excluding the business income deduction 
        and the deduction of prior year 168(k) and 179 depreciation add-backs)
35        
       List the deductions here: ________________________________________________________ ..................8.
36                                                                                                                                                              12345678901 
     9. Total (Sum of lines 1 through 7, minus line 8, Column B only)..........................................................................9.
37                                                                                                                                                              12345678901 
38 Part B - Complete only for taxpayers who are part-year residents of Ohio. 
39
   10. Nonbusiness interest and dividend income.......................................................10.
40                                                                                                                12345678901                                   12345678901 
   11.  Pensions, annuities and IRA distributions .........................................................11.
41                                                                                                                12345678901                                   12345678901 
   12. Unemployment compensation...........................................................................12.
42                                                                                                                12345678901                                   12345678901 
   13. Other nonbusiness income ...............................................................................13.
43                                                                                                                12345678901                                   12345678901 
44 14. Deductions from your federal return included in federal adjusted gross
45     income. List the deductions here:
                                                                               .......14.  
46                                                                                                                12345678901                                   12345678901 
   15. Total (Sum of lines 10 through 13, minus line 14, Column B only)..................................................................15.  
47                                                                                                                                                              12345678901 
48 Part C - Calculation of the Nonresident Portion of Ohio Adjusted Gross Income. 

49 16. Ohio Adjusted Gross Income (from Ohio IT 1040, line 3) .....................................................16.                                          12345678901 
50
     17. Total Income Allocated or Apportioned to Ohio (line 9 plus line 15; 
51      if negative, enter zero) .........................................................................................................17.                   12345678901 
52 18. Nonresident Portion of Ohio Adjusted Gross Income (line 16 minus line 17; 
53     if negative enter zero) .........................................................................................................18.                     12345678901 
54
55 19. Divide line 18 by line 16. Carry to 4 digits without rounding. If greater than 1, enter 1 .......19.                                                     0.1234
56
   20.  Ohio Nonresident Credit. Multiply line 19 by Ohio Schedule of Credits, line 35. 
57     Enter here and on the Ohio Schedule of Credits, line 36 ....................................................20.                                          12345678901 
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.
64                                                                                                                                               2023 IT NRC – page 1 of 3
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2
3
4
                                                                            2023 IT NRC
5
6   SSN:       216 01 0123                                                                                                                                    10211411
7
8  Section II – Ohio Business Income
9  Report each business from which the taxpayer received business income or loss during the tax year. List the businesses in descending 
10 order from highest “Ohio Apportioned Income” to lowest, including those businesses with no Ohio apportionment.
11
12 Use Section III of this form to calculate the amounts reported in Columns B and C. Certain taxpayers who receive an Ohio IT K-1 may be 
13 able to attach a copy of the form in lieu of completing Section III for that entity. Such taxpayers should check the box and report the IT K-1 
   amounts in Columns B and C. Section III is not required for businesses with no Ohio apportionment.
14
15 Important: “Federal Business Income” is the taxpayer’s share of income they reported for federal income tax purposes.                                              Column A is 
16 NOT a total of Columns B and C.
17
                                                                            (A)              (B)                                                              (C)
18                                        IT K-1                            Federal Business Ohio Depreciation                                                Ohio Apportioned 
19                                                                          Income            Adjustment                                                      Income
20
     1.  FEIN/SSN:                               1.
21
22   2.  FEIN/SSN:                               2.
23   3.  FEIN/SSN:                               3.
24   4.  FEIN/SSN:                               4.
25
     5.  FEIN/SSN:                               5.
26
27   6.  FEIN/SSN:                               6.
28   7.  FEIN/SSN:                               7.
29   8.  FEIN/SSN:                               8.
30
     9.  FEIN/SSN:                               9.
31
32 10.  FEIN/SSN:                                10.
33 11.  FEIN/SSN:                                11.
34 12.  FEIN/SSN:                                12.
35
   13.  FEIN/SSN:                                13.
36
37 14.  FEIN/SSN:                                14.
38 15.  FEIN/SSN:                                15.
39 16.  FEIN/SSN:                                16.
40
   17.  FEIN/SSN:                                17.
41
42 18.  FEIN/SSN:                                18.
43 19.  FEIN/SSN:                                19.
44 20.  FEIN/SSN:                                20.
45
46 21.  Enter the total of all additional 
47         businesses, if any........................................21.
48 22.  Totals (sum of lines 1 through 21,
49          by column)..................................................22. 
50
    
51 Enter the total from line 22, Column B on Section 1, line 6.
52
53 If line 22, Column C is zero or less, STOP HERE and enter that amount on Section I, line 5. Otherwise, continue to lines 23 and 24.
54
55 23.  Business Income Deduction (from the Ohio Schedule of Business Income, line 13) ........................... 23.
56
57 24.  Ohio Business Income (line 22, Column C minus line 23; if less than zero, enter zero).  Enter here 
58     and on Section I, line 5.................................... ...................................................................................... 24.
59
60
61
62
63
64                                                                                                             2023 IT NRC – page 2 of 3
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66

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
                                                                  2023 IT NRC
5
6   SSN: 216 01 0123                                                                                                                                   10211411
7
8  Section III – Business-Level Income & Apportionment
9  Complete a separate Section III for each business with Ohio apportionment. If the taxpayer is allowed to use the IT K-1 to report income 
10 from the pass-through entity, do not complete Section III for that entity.
11                                                                                     Primary
12                                                                                     Spouse
13
14  Business name / description                                                   Owner (check % ownership                                                FEIN (entities only)
                                                                                  one only)
15
16 Part A – Apportionment Ratio for This Business (see instructions for details)
17
18
                                                              (A)            (B)               (C)                                                    (D)           (E)
19                                                                          Total                                                                                  Weighted
20                                                            Within Ohio   Everywhere         Ratio                                            Weight              Ratio
21   1. Property                                                                              (carry to six                                                     (carry to six
22     (a) Owned (average cost) ...............                                              decimal spaces)                                                    decimal spaces)
23     (b) Rented (annual rental x 8).........
                                                                          /            =
24    (c) Total (line 1a plus line 1b) ..........                                          .                                                    x .20     = 1c.    .
25
26    2. Payroll.............................................             /            =   .                                                    x .20     = 2.     .
27   3. Sales...............................................              /            =   .                                                    x .60     = 3.     .
28   4. Ohio apportionment ratio. Add lines 1c, 2 and 3........................................................................................................ 4. .
29
    
30
31 Part B – Apportionable Business Income & Deductions
32     Include on these lines all amounts, included on the taxpayer’s federal filing, that constitute business income. See R.C. 5747.01(B).
33
34   5. Schedule B - Interest and Ordinary Dividends   ........................................................................................5.
35   6. Schedule C - Net Profit or Loss from Business ........................................................................................6.
36
37   7. Schedule D - Capital Gains and Losses (excluding R.C. 5747.212 amounts) .........................................7.
    
38   8. Schedule E - Supplemental Income & Loss (excluding guaranteed payments) .......................................8.
39   9. Guaranteed payments, wages and/or compensation from a pass-through entity in which the taxpayer
40     has at least a 20% direct or indirect ownership interest ...........................................................................9.   
41   10. Schedule F - Net Profit or Loss from Farming ........................................................................................10.   
42
    11. Other business income and/or federal conformity additions reported on Ohio Schedule of Adjustments  ....11.
43
44   12. Other business deductions and/or federal conformity deductions reported on Ohio Schedule of Adjustments ....12.
45   13. Total of business income (sum of lines 5 through 11 minus line 12) ......................................................13.  
46   14. Income apportioned to Ohio (multiply line 4 by line 13)..........................................................................14.
47
     15. Total R.C. 5747.212 business income.................................................................................................... 15.   
48
49   16. R.C. 5747.212 income apportioned to Ohio (enclose detailed computations) .......................................16.   
    
50 17. Ohio Apportioned Income (line 14 plus line 16). Enter here and on the corresponding line for this 
51     business in Section II, Column C............................................................................................................17.
52  
53 Part C – Apportionable Ohio Depreciation Adjustments from Ohio Schedule of Adjustments
54     Include on these lines only amounts representing Ohio’s add-back and corresponding deductions for Internal Revenue Code section  
55   168(k) & 179 depreciation expense that are reported on Ohio Schedule of Adjustments and are attributable to the entity above.
56   18. IRC 168(k) & 179 depreciation expense add-back ................................................................................18.
57
   19. Deduction of prior year 168(k) and 179 depreciation add-backs ...........................................................19.
58
59   20. Net apportionable Ohio Schedule of Adjustments depreciation adjustment (line 18 minus line 19) ...... 20.
60   21. Ohio Apportioned Depreciation Adjustment (multiply line 4 by line 20).  Enter here and on the
61     corresponding line for this business in Section II, Column B................................................................. 21.
62
63
64                                                                                                              2023 IT NRC – page 3 of 3
65
66

Layout 

Without Grid

Do not staple or paper clip.
2023 Ohio IT 1040 
Individual Income Tax Return
23000110
12 15 24 Use only black ink/UPPERCASE letters. Use whole dollars only.  Sequence No. 1

 X AMENDED RETURN - Check here and include Ohio IT RE. X NOL CARRYBACK - Check here and include Schedule IT NOL.
 
Primary taxpayer's SSN (required) If deceased Spouse’s SSN (if filing jointly) If deceased School district # 
216 01 1234 X 417 01 1234 X 2307

First name M.I. Last name
JOHN BC'EF-HIJK Q  PUBLICA CDE-GHIJ'LMNOX
Spouse's first name (if filing jointly) M.I. Last name
JANEAB DE'GHI-K Q PUBLICA CDE-GHIJ'LMNOX
Address line 1 (number and street) or P.O. Box
1234 CHERRY LANEABCDE&G-IJKLMN/PQRS
Address line 2 (apartment number, suite number, etc.)
1234 CHERRY LANEAB DE-GH&JKLMN/PQRS
City State ZIP code Ohio county (first four letters)

CITYA CDEFGHIJKLMNOX OH 12345 FRAN
Foreign country (if the mailing address is outside the U.S.) Foreign postal code
JAPANABCDEFGH IJKLMO X8X8X8X
Residency Status – Check only one for primary *Indicate state Filing Status – Check one (as reported on federal income tax return)
X Resident X Part-year X Nonresident* GA X Single, head of household or qualifying surviving spouse
resident*
Check only one for spouse (if filing jointly) *Indicate state Married filing jointly                  
Resident Part-year Nonresident* X  Spouse’s SSN
X X X NY
resident* X Married filing separately216 01 1234
Ohio Nonresident Statement – See instructions for required criteria
X Primary meets the five criteria for irrebuttable presumption as nonresident. X Federal extension filers - check here.

X Spouse meets the five criteria for irrebuttable presumption as nonresident. X If someone can claim you (or your spouse if filing jointly) as a 
dependent, check here.
 
  1. Federal adjusted gross income (federal 1040 or 1040-SR, line 11). Place a "-" in the box  
if negative .......................................................................................................................................... -  ....1. 12345678901
 
  2a. Additions – Ohio Schedule of Adjustments, line 11 (include schedule) ....................................................2a. 12345678901
 
2b. Deductions Ohio– Schedule of Adjustments, line 44 (include schedule) .................................................2b. 12345678901
 
  3. Ohio adjusted gross income (line 1 plus line 2a minus line 2b). Place a "-" in the box if negative ..  -  ....3. 12345678901
Do not staple or paper clip. 

  4. Exemption amount (include Schedule of Dependents if applicable) ..............   .............................4. 12345
      Number of exemptions including you and your spouse/dependents, if applicable: 12
 
  5. Ohio income tax base (line 3 minus line 4; if negative, enter zero)...............................................................5. 12345678901
 
  6. Taxable business income – Ohio Schedule of Business Income, line 15 (include schedule) .....................6. 123456789

  7. Taxable nonbusiness income (line 5 minus line 6; if negative, enter zero) ...................................................7. 12345678901

Software vendors: Place 2D barcode in this location
MM-DD-YY
Do not place a box around the 2D barcode. The box 
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2023 IT 1040 – page 1 of 2

                                                                  2023 Ohio IT 1040 
                                                               Individual Income Tax Return
SSN:       216 01 1234                                                                                                                                                      23000210  Sequence No. 2

  7a. Amount from line 7 on page 1  ....................................................................................................................7a.                  12345678901
 
  8a. Nonbusiness income tax liability on line 7a (see instructions for tax tables)...........................................................8a.                            123456789
 
  8b. Business income tax liability – Ohio Schedule of Business Income, line 16 (include schedule) ..........................8b.                                                     1234567

  8c. Income tax liability before credits (line 8a plus line 8b) ..........................................................................................8c.               123456789

  9. Ohio nonrefundable credits – Ohio Schedule of Credits, line 38 (include schedule) ..............................................9.                                      123456789

  10. Tax liability after nonrefundable credits (line 8c minus line 9; if negative, enter zero) ............................................10.                              123456789

  11. Interest penalty on underpayment of estimated tax (include Ohio IT/SD 2210) ....................................................11.                                    123456789

12. Unpaid use tax (see instructions) ............................................................................................................................12.        123456789

  13. Total Ohio tax liability before withholding or estimated payments (add lines 10, 11 and 12) ...............................13.                                         123456789
  14. Ohio income tax withheld – Schedule of Ohio Withholding, part A, line 1 (include schedule and
    income statements) ..............................................................................................................................................14.     123456789

15. Estimated and extension payments, and credit carryforward from last year's return ..............................................15.                                      123456789

  16. Refundable credits – Ohio Schedule of Credits, line 44 (include schedule) .........................................................16.                                 123456789

  17. Amended return only – amount previously paid with original and/or amended return .........................................17.                                          123456789

  18. Total Ohio tax payments (add lines 14, 15, 16 and 17) ........................................................................................18.                      123456789

  19. Amended return only – overpayment previously requested on original and/or amended return ..........................19.                                                 123456789

  20. Line 18 minus line 19. Place a "-" in the box if negative ................................................................................. -  ......20.               123456789
           If line 20 is MORE THAN line 13, skip to line 24. OTHERWISE, continue to line 21.
  21. Tax due (line 13 minus line 20). If line 20 is negative, ignore the "-" and add line 20 to line 13..............................21.                                    123456789

 22. Interest due on late payment of tax (see instructions) ............................................................................................................22.  123456789
 
23.TOTAL AMOUNT DUE            (line 21 plus line 22).    Include the Ohio Universal Payment 
    Coupon (OUPC) and make check payable to “Ohio Treasurer of State” .............................. AMOUNT DUE23.                                                          123456789

  24. Overpayment (line 20 minus line 13) ......................................................................................................................24.          123456789
 
  25. Original return only – portion of line 24 carried forward to next year’s tax liability .................................................25.                            123456789
  26. Original return only – portion of line 24 you wish to donate:
      a.  Wishes for Sick Children           b . Wildlife Species                 c.  Military Injury Relief
           1234                                        1234                             1234
                                                                                                                                  Total ....26g.                             123456789
        d.  Ohio History Fund      e.  Nature Preserves/Scenic Rivers             f.  Breast/Cervical Cancer
           1234                                        1234                             1234
 27. REFUND (line 24 minus lines 25 and 26g) .............................................................................YOUR  REFUND27.                                   123456789
Sign Here (required): I have read this return. Under penalties of perjury, I declare that, to the best of my knowledge                            If your refund is $1.00 or less, no refund will be issued. 
and belief, the return and all enclosures are true, correct and complete.                                                                           If you owe $1.00 or less, no payment is necessary.
Primary signature                                                                Phone number                                                              NO Payment Included  –Mail to:
                                                                                                                                                                     Ohio Department of Taxation
 Spouse’s signature                                                       Date                                                                                              P.O. Box 2679
                                                                                                                                                                    Columbus, OH  43270-2679
Preparer's printed name                                                           Phone number                                                                       Payment Included  –Mail to:
                                                                                                                                                                     Ohio Department of Taxation
                                                                                                                                                                            P.O. Box 2057
         X Authorize your preparer to   X Non-paid preparer               PTIN:   P     01234567                                                                     Columbus, OH  43270-2057
           discuss this return
                                                                                                                                                                     2023 IT 1040 – page 2 of 2

                                                    2023 Ohio Schedule 
                                                    of Adjustments
                                                    Use only black ink. Use whole dollars only.                                                                             23000310
                                                          Primary taxpayer’s SSN
                                                                                                                                                                                    Sequence No. 3
01 15 24                                                  216 01 0123
                                                          Additions 
                               (Only add the following amounts if they are not included on Ohio IT 1040, line 1)

  1.  Non-Ohio state or local government interest and dividends ....................................................................................1.                      123456789

  2.  Ohio pass-through entity taxes excluded from federal adjusted gross income .......................................................2.                                  123456789
   
  3.  Taxes paid to another state or District of Columbia related to IRS notice 2020-75 .................................................3.                                 123456789

  4.  529 plan funds used for non-qualified expenses .....................................................................................................4.                        123456

  5.  Losses from sale or disposition of Ohio public obligations ......................................................................................5.                   123456789
 
  6.  Nonmedical withdrawals from a medical savings account ......................................................................................6.                        123456789
 
  7.  Reimbursement of expenses previously deducted on an Ohio income tax return ..................................................7.                                       123456789
Federal

   8.  Internal Revenue Code 168(k) and 179 depreciation expense add-back ...............................................................8.                                 123456789

  9.  Exempt federal interest and dividends subject to state taxation .............................................................................9.                       123456789

 10.  Federal conformity additions .................................................................................................................................10.     123456789

  11.  Total additions (add lines 1 through 10 ONLY). Enter here and on Ohio IT 1040, line 2a ........................ 11.                                                  12345678901
                                                          Deductions 
                               (Only deduct the following amounts if they are included on Ohio IT 1040, line 1)
      
 12.  Business income deduction – Ohio Schedule of Business Income, line 13 ..........................................................12.                                           123456
 
 13.  Employee compensation earned in Ohio by residents of neighboring states ..........................................................13.                                 123456789

 14.  Taxable refunds, credits, or offsets of state and local income taxes (federal 1040, Schedule 1, line 1) ...............14.                                            123456789

 15.  Taxable Social Security benefits (federal 1040 and 1040-SR, line 6b) .................................................................15.                             123456789
 
 16.  Certain railroad benefits ........................................................................................................................................16. 123456789
 17.  Interest income from Ohio public obligations and purchase obligations; gains from the 
     disposition of Ohio public obligations; or income from a transfer agreement ........................................................17.                                123456789

 18.  Amounts contributed to an Ohio county's individual development account program ............................................18.                                        123456789

 19.  Amounts contributed to a STABLE account: Ohio's ABLE plan ............................................................................19.                             123456789
 
 20.  Income earned in Ohio by a qualifying out-of-state business or employee for disaster  
      work conducted during a disaster response period ...............................................................................................20.                   123456789

 21.  Certain payments related to the East Palestine train derailment ..........................................................................21.                         123456789

 22.  Ohio adoption grant program payments received from the Ohio Department of Job and Family Services ..........22.                                                       123456789
Federal

 23.  Federal interest and dividends exempt from state taxation ...................................................................................23.                      123456789

                                                                                            2023 Schedule of Adjustments – page 1 of 2

                                                      2023 Ohio Schedule 
                                                                of Adjustments
                                                                                                                                                                                 23000410
                                                                Primary taxpayer’s SSN
                                                                                                                                                                                         Sequence No. 4
                                                                216 01 0123

  24.    Deduction of prior year 168(k) and 179 depreciation add-backs ..........................................................................24.                             123456789
 
  25.  Refund or reimbursements from the federal 1040, Schedule 1, line 8z for federal itemized deductions 
       claimed on a prior year return ..............................................................................................................................25.          123456789
 
  26.  Repayment of income reported in a prior year .....................................................................................................26.                     123456789

  27.  Wage expense not deducted based on the federal work opportunity tax credit ...................................................27.                                         123456789
  28.   Federal conformity deductions ...............................................................................................................................28.
                                                                                                                                                                                 123456789
Uniformed Services

   29.  Military pay received by Ohio residents while stationed outside Ohio ..................................................................29.                               123456789

  30.  Compensation earned by nonresident military servicemembers and their civilian spouses ..................................30.                                               123456789

  31.  Uniformed services retirement income .................................................................................................................31.                 123456789

  32.  Military injury relief fund grants and veteran’s disability severance payments ...........................................................32.                             123456789

   33.  Certain Ohio National Guard reimbursements and benefits .................................................................................33.                             123456789
 
Education

  34.  Amounts contributed to a 529 Plan ......................................................................................................................34.                       123456
 
  35.  Pell/Ohio College Opportunity taxable grant amounts used to pay room and board ...........................................35.                                                     123456

  36.  Ohio educator expenses in excess of federal deduction ......................................................................................36.                                   123
  37.  Income attributable to loan repayments by the Ohio Department of Higher Education under the rural 
       practice incentive program ...................................................................................................................................37.                 12345

  38.  Grant program payments made by the Ohio Department of Higher Education on behalf of adopted students ...38.                                                                       1234
Medical

  39.   Disability benefits .................................................................................................................................................39. 123456789

  40.  Survivor benefits ...................................................................................................................................................40.  123456789

  41.  Unreimbursed medical and health care expenses (see instructions for worksheet; include a copy) .................41.                                                       123456789

  42.  Medical savings account contributions/earnings (see instructions for worksheet; include a copy) ....................42.                                                   123456789

  43.  Qualified organ donor expenses ..........................................................................................................................43.                      12345

  44.  Total deductions (add lines 12 through 43 ONLY). Enter here and on Ohio IT 1040, line 2b............................44.                                                   12345678901

                                                                                       2023 Schedule of Adjustments – page 2 of 2

                                                                  2023 Ohio Schedule
                                                                   of Business Income
                                                                                                                                                                                   23260110
                                                                  Use only black ink/UPPERCASE letters.
                                                                             Primary taxpayer’s SSN
                                                                                                                                                                                           Sequence No. 5
 01 15 24                                                                    216 01 0123
  Enter all business income that you (and your spouse, if filing jointly) received during the tax year on this schedule. Enter only those amounts that are 
  included in your federal adjusted gross income. Only one Schedule of Business Income should be used for each return filed. See R.C. 5747.01(B). 
  Use whole dollars only. 
  Part 1 – Business Income
  Note: Do not include amounts listed on the IRS schedules below that are nonbusiness income. 
  See R.C. 5747.01(C). If the amount on a line is negative, place a “-“ in the box provided.

   1. Schedule B – Interest and Ordinary Dividends ........................................................................................................1.                      123456789
  
   2. Schedule C – Net Profit or Loss From Business (Sole Proprietorship) ......................................................                  -  ...2.                         123456789
  
   3. Schedule D – Capital Gains and Losses ....................................................................................................  -  ...3.                         123456789
  
   4. Schedule E – Supplemental Income and Loss...........................................................................................        -  ...4.                         123456789

   5. Guaranteed payments or compensation from a pass-through entity to a 20% or greater direct                
     or indirect owner ......................................................................................................................................................5.    123456789

   6. Schedule F – Net Profit or Loss From Farming ..........................................................................................     -  ...6.                         123456789

   7. Add-back of electing pass-through entity taxes paid on the Ohio form IT 4738 that qualify as business income ....7.                                                          123456789
   8. Add-back of taxes paid to another state or the District of Columbia related to IRS notice 2020-75 that 
     qualify as business income ......................................................................................................................................8.           123456789

   9. Other business income or loss not reported above (e.g. form 4797 amounts) ..........................................                        -  ...9.                         123456789

  10. Total business income (add lines 1 through 9) ...........................................................................................   -  .10.                          123456789
 Part 2 – Business Income Deduction
  11. Enter the lesser of line 10 above or Ohio IT 1040, line 1. If negative, enter zero; 
      stop here and do not complete Part 3 ...................................................................................................................11.                  123456789
  12. Enter $250,000 if filing status is single or married filing jointly; OR
     Enter $125,000 if filing status is married filing separately ......................................................................................12.                                123456

  13. Enter the lesser of line 11 or line 12. Enter here and on Ohio Schedule of Adjustments, line 12 .................................13.                                                 123456
 Part 3 – Taxable Business Income

  Note: If Ohio IT 1040, line 5 is zero, do        not complete Part 3.
  14. Line 11 minus line 13      ..............................................................................................................................................14. 123456789
  15. Taxable business income (enter the lesser of line 14 above or Ohio IT 1040, line 5).   Enter here and 
     on Ohio IT 1040, line 6 ...........................................................................................................................................15.        123456789
  
  16. Business income tax liability – multiply line 15 by 3% (.03). Enter here and on Ohio IT 1040, line 8b ......................16.                                              1234567

                Software vendors: Place 2D barcode in this location
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                              is only here for placement purposes.

                                                                                                   2023 Schedule of Business Income – page 1 of 2

                                2023 Ohio Schedule
                                 of Business Income
                                             Primary taxpayer’s SSN                                         23260210

                                             216 01 0123                                                            Sequence No. 6
Part 4 – Business Sources
List all sources of business income, with Ohio sources listed first. Also separately list your ownership percentage and/or your spouse’s ownership percent-
age (if filing jointly). If necessary, complete additional copies of this page and include with your return.

  1. FEIN / SSN          Primary ownership   Spouse’s ownership

     123456789           050.00            % 050.00 %
                         .                   .
     Business name

     QUICK-BROWNFOX&THE’COWJUMPEDTHE 3/4 MOON
  2. FEIN / SSN          Primary ownership   Spouse’s ownership

     123456789           050.00            % 050.00 %
                         .                   .
     Business name

     QUICK-BROWNFOX&THE’COWJUMPEDTHE 3/4 MOON
  3. FEIN / SSN          Primary ownership   Spouse’s ownership

     123456789           050.00            % 050.00 %
                         .                   .
     Business name

     QUICK-BROWNFOX&THE’COWJUMPEDTHE 3/4 MOON
  4. FEIN / SSN          Primary ownership   Spouse’s ownership

     123456789           050.00            % 050.00 %
                         .                   .
     Business name

     QUICK-BROWNFOX&THE’COWJUMPEDTHE 3/4 MOON
  5. FEIN / SSN          Primary ownership   Spouse’s ownership

     123456789           050.00            % 050.00 %
                         .                   .
     Business name

     QUICK-BROWNFOX&THE’COWJUMPEDTHE 3/4 MOON
  6. FEIN / SSN          Primary ownership   Spouse’s ownership

     123456789           050.00            % 050.00 %
                         .                   .
     Business name

     QUICK-BROWNFOX&THE’COWJUMPEDTHE 3/4 MOON
  7. FEIN / SSN          Primary ownership   Spouse’s ownership

     123456789           050.00            % 050.00 %
                         .                   .
     Business name

     QUICK-BROWNFOX&THE’COWJUMPEDTHE 3/4 MOON
  8. FEIN / SSN          Primary ownership   Spouse’s ownership

     123456789           050.00            % 050.00 %
                         .                   .
     Business name

     QUICK-BROWNFOX&THE’COWJUMPEDTHE 3/4 MOON

                                                                    2023 Schedule of Business Income – page 2 of 2

                                                                           2023 Ohio Schedule of Credits
                                                                                Use only black ink. Use whole dollars only.
                                                                                                 Primary taxpayer’s SSN                                                          23280110
                                                                                                                                                                                         Sequence No. 7
    01 01 01                                                                                     123 45 6789
         Many of these credits must be calculated using a worksheet and/or be supported by additional required documentation. See the instructions for 
         worksheets and information on supporting documentation.

                                                                                                 Nonrefundable Credits
     1.  Tax liability before credits (from Ohio IT 1040, line 8c) ............................................................................................1.                        123456789

     2.  Retirement income credit (include 1099-R forms) .................................................................................................2.                             123

     3.  Lump sum retirement credit (include a copy of the worksheet and 1099-R forms) ..........................................3.                                                      123456

     4.  Senior citizen credit (must be 65 or older to claim this credit) ...............................................................................4.                              12
   
     5.  Lump sum distribution credit (include a copy of the worksheet and 1099-R forms) .........................................5.                                                     1234

     6.  Child care & dependent care credit (include a copy of the worksheet) ..............................................................6.                                           1234

     7.  Displaced worker training credit (include a copy of the worksheet and all required documentation) ................7.                                                            1234

     8.  Campaign contribution credit for Ohio statewide office or General Assembly .......................................................8.                                            123

     9.  Exemption credit ....................................................................................................................................................9.         123
   
    10.  Total (add lines 2 through 9) ................................................................................................................................10.               123456789

    11.  Tax less credits (line 1 minus line 10; if negative, enter zero) .............................................................................. 11.                             123456789
   
    12.  Joint filing credit (see instructions for table).               % times01line 11, up to $650    ..............................................................12.               123

    13.  Earned income credit ...........................................................................................................................................13.             1234

    14.  Home school expenses credit (include copies of all required documentation) ..............................................14.                                                    123

    15.  Scholarship donation credit (include copies of all required documentation) ..................................................15.                                                1234

    16.  Nonchartered, nonpublic school tuition credit (include copies of all required documentation) ......................16.                                                          1234

    17.  Credit for work-based learning experiences (include a copy of the credit certificate) ....................................17.                                                   1234567

    18.  Ohio adoption credit carryforward ........................................................................................................................18.                   1234567

    19.  Nonrefundable job retention credit (include a copy of the credit certificate) ...................................................19.                                            1234567

    20.  Credit for eligible new employees in an enterprise zone (                               include a copy of the credit certificate) .................20.                          1234567

     21.  Credit for the beginning farmers financial management program (include a copy of the credit certificate) ....21.                                                               1234567

    22.  Welcome Home Ohio credit (include a copy of the credit certificate) .............................................................22.                                            1234567

    23.  Credit for sale/rental of agricultural assets to beginning farmers (                        include a copy of the credit certificate) .....23.                                  1234567

                      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.
                                                                                                                           2023 Schedule of Credits – page 1 of 2

                                                2023 Ohio Schedule of Credits
                                                               Primary taxpayer’s SSN
                                                                                                                                                                         23280210
                                                                  123 45 6789                                                                                                    Sequence No. 8

 24.  Grape production credit .......................................................................................................................................24.         1234567

  25.  InvestOhio credit (include a copy of the credit certificate) ..............................................................................25.                            1234567

  26.  Lead abatement credit (include a copy of the credit certificate) .....................................................................26.                                 1234567

  27.  Opportunity zone investment credit (include a copy of the credit certificate) .................................................27.                                        1234567
 
  28.  Technology investment credit carryforward (include a copy of the credit certificate) ......................................28.                                            1234567

  29.  Enterprise zone day care & training credits (include a copy of the credit certificate) .....................................29.                                           1234567

  30.  Research & development credit (include a copy of the credit certificate) .......................................................30.                                       1234567

  31.  Nonrefundable Ohio historic preservation credit (include a copy of the credit certificate) ..............................31.                                              1234567

  32.  Ohio low-income housing credit (include a copy of the credit certificate) .......................................................32.                                      1234567
 
  33.  Affordable single-family housing credit (include a copy of the credit certificate) ............................................33.                                        1234567

  34.  Total (add lines 12 through 33) ............................................................................................................................34.           123456789

  35.  Tax less additional credits (line 11 minus line 34; if negative, enter zero)............................................................35.                               123456789
  Residency Credits
 36.  Nonresident credit – Ohio IT NRC, line 20 (include a copy) ..............................................................................36.                               123456789

  37.  Resident credit – Ohio IT RC, line 7 (include a copy) ........................................................................................37.                         123456789

  38. Total nonrefundable credits (add lines 10, 34, 36 and 37; enter here and on Ohio IT 1040, line 9) ................38.                                                      123456789

                                                                  Refundable Credits

  39.  Refundable Ohio historic preservation credit (include a copy of the credit certificate) ...................................39.                                            12345678
 
  40.  Refundable job creation credit & job retention credit (include a copy of the credit certificate) ................................40.                                      12345678

  41.  Pass-through entity credit (include a copy of all Ohio IT K-1s) ........................................................................41.                               12345678

  42.  Motion picture & Broadway theatrical production credit (include a copy of the credit certificate) ...................42.                                                  12345678
 
  43.  Venture capital credit (include a copy of the credit certificate) .......................................................................43.                              12345678
 
  44. Total refundable credits (add lines 39 through 43; enter here and on Ohio IT 1040, line 16) ...........................44.                                                 123456789

                                                                                                       2023 Schedule of Credits – page 2 of 2

                       2023 Ohio Schedule 
                         of Dependents
                       Use only black ink/UPPERCASE letters.                                   23230110
                            Primary taxpayer's SSN
                                                                                                                              Sequence No. 9
01 15 23                    216 01 0123
Do not list the primary filer and/or spouse (if filing jointly) as dependents on this schedule. 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” if necessary. 

  1. Dependent’s SSN   Dependent's date of birth (MM-DD-YYYY)                                  Dependent’s relationship to you

867 53 0950            12 12 2015                                                              ITSMY OFFSPRING
Dependent’s first name M.I. Dependent's last name
AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI
  2. Dependent’s SSN   Dependent's date of birth (MM-DD-YYYY)                                  Dependent’s relationship to you
867 53 0950            12 12 2015                                                              ITSMY OFFSPRING
Dependent’s first name M.I. Dependent's last name
AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI
  3. Dependent’s SSN   Dependent's date of birth (MM-DD-YYYY)                                  Dependent’s relationship to you

867 53 0950            12 12 2015                                                              ITSMY OFFSPRING
Dependent’s first name M.I. Dependent's last name
AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI
  4. Dependent’s SSN   Dependent's date of birth (MM-DD-YYYY)                                  Dependent’s relationship to you
867 53 0950            12 12 2015                                                              ITSMY OFFSPRING
Dependent’s first name M.I. Dependent's last name
AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI
  5. Dependent’s SSN   Dependent's date of birth (MM-DD-YYYY)                                  Dependent’s relationship to you
867 53 0950            12 12 2015                                                              ITSMY OFFSPRING
Dependent’s first name M.I. Dependent's last name
AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI
  6. Dependent’s SSN   Dependent's date of birth (MM-DD-YYYY)                                  Dependent’s relationship to you

867 53 0950            12 12 2015                                                              ITSMY OFFSPRING
Dependent’s first name M.I. Dependent's last name
AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI
  7. Dependent’s SSN   Dependent's date of birth (MM-DD-YYYY)                                  Dependent’s relationship to you
867 53 0950            12 12 2015                                                              ITSMY OFFSPRING
Dependent’s first name M.I. Dependent's last name 
AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI

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.

                                                                                               2023 Schedule of Dependents – page 1 of 2

                       2023 Ohio Schedule 
                         of Dependents 
                                                              23230210
                            Primary taxpayer's SSN
                                                                                              Sequence No. 10
                            216 01 0123
  8. Dependent’s SSN   Dependent's date of birth (MM-DD-YYYY) Dependent’s relationship to you

867 53 0950            12 12 2015                             ITSMY OFFSPRING
Dependent’s first name M.I. Dependent's last name
AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI
  9. Dependent’s SSN   Dependent's date of birth (MM-DD-YYYY) Dependent’s relationship to you
867 53 0950            12 12 2015                             ITSMY OFFSPRING
Dependent’s first name M.I. Dependent's last name
AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI
  10. Dependent’s SSN  Dependent's date of birth (MM-DD-YYYY) Dependent’s relationship to you 
867 53 0950            12 12 2015                             ITSMY OFFSPRING
Dependent’s first name M.I. Dependent's last name
AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI
  11. Dependent’s SSN  Dependent's date of birth (MM-DD-YYYY) Dependent’s relationship to you
867 53 0950            12 12 2015                             ITSMY OFFSPRING
Dependent’s first name M.I. Dependent's last name
AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI
  12. Dependent’s SSN  Dependent's date of birth (MM-DD-YYYY) Dependent’s relationship to you
867 53 0950            12 12 2015                             ITSMY OFFSPRING
Dependent’s first name M.I. Dependent's last name
AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI
  13. Dependent’s SSN  Dependent's date of birth (MM-DD-YYYY) Dependent’s relationship to you
867 53 0950            12 12 2015                             ITSMY OFFSPRING
Dependent’s first name M.I. Dependent's last name
AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI
  14. Dependent’s SSN  Dependent's date of birth (MM-DD-YYYY) Dependent’s relationship to you
867 53 0950            12 12 2015                             ITSMY OFFSPRING
Dependent’s first name M.I. Dependent's last name
AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI
15. Dependent’s SSN    Dependent's date of birth (MM-DD-YYYY) Dependent’s relationship to you
867 53 0950            12 12 2015                             ITSMY OFFSPRING
Dependent’s first name M.I. Dependent's last name
AB-DEFGH IJ'LMN        Q    PRS-UVWXYZ ABCD'FGHI

                                                              2023 Schedule of Dependents – page 2 of 2

                                            2023 Schedule of Ohio 
                                                                    Withholding 
                            Use only black ink/UPPERCASE letters. Use whole dollars only.                                                                23350110
                                                                    Primary taxpayer’s SSN                                                                        Sequence No. 11

                                                                    216 01 0123
  List your and your spouse’s (if filing jointly) income statements only if they have Ohio withholding. In the “P/S” box, if the income statement belongs to the 
  primary taxpayer, enter “P”; if the income statement belongs to the spouse, enter “S”. If the Ohio ID number on a statement has 9 digits, enter only the first 
  8 digits. Complete additional copies of this schedule if necessary. Include state copies of your income statements.
  Part A - Total Withholding
  1. Total of all Ohio state tax withheld on pages 1 and 2 as well as any additional pages. Enter here 
    and on line 14 of your Ohio IT 1040 ..............................................................................................................1. 123456789
  Part B - W-2s
  1. P/S Box b - EIN                        Box 1 - Wages, tips, other compensation                    Box 2 - Federal income tax withheld
     P   123456789                          123456789                                                  12345678
         Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc.                                                                              Box 17 - Ohio income tax
         12345678                           123456789                                                                                                    12345678
  2. P/S Box b - EIN                        Box 1 - Wages, tips, other compensation                    Box 2 - Federal income tax withheld
     S   123456789                          123456789                                                  12345678
         Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc.                                                                              Box 17 - Ohio income tax
         12345678                           123456789                                                                                                    12345678
  3. P/S Box b - EIN                        Box 1 - Wages, tips, other compensation                    Box 2 - Federal income tax withheld
     P   123456789                          123456789                                                  12345678
         Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc.                                                                              Box 17 - Ohio income tax
         12345678                           123456789                                                                                                    12345678
  4. P/S Box b - EIN                        Box 1 - Wages, tips, other compensation                    Box 2 - Federal income tax withheld
     S   123456789                          123456789                                                  12345678
         Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc.                                                                              Box 17 - Ohio income tax
         12345678                           123456789                                                                                                    12345678
  5. P/S Box b - EIN                        Box 1 - Wages, tips, other compensation                    Box 2 - Federal income tax withheld
     P   123456789                          123456789                                                  12345678
  
         Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc.                                                                              Box 17 - Ohio income tax
         12345678                           123456789                                                                                                    12345678
  6. P/S Box b - EIN                        Box 1 - Wages, tips, other compensation                    Box 2 - Federal income tax withheld
     S   123456789                          123456789                                                  12345678
         Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc.                                                                              Box 17 - Ohio income tax
         12345678                           123456789                                                                                                    12345678
  7. P/S Box b - EIN                        Box 1 - Wages, tips, other compensation                    Box 2 - Federal income tax withheld
     P   123456789                          123456789                                                  12345678
         Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc.                                                                              Box 17 - Ohio income tax
         12345678                           123456789                                                                                                    12345678
 
               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.
                                                                                                       2023 Schedule of Withholding – page 1 of 2

                                       2023 Schedule of Ohio 
                                       Withholding 
                                       Primary taxpayer’s SSN                             23350210
  Part C - 1099-Rs                         216 01 0123                                            Sequence No. 12
  1. P/S Payer’s TIN                   Box 1 - Gross distribution
                                                                           Total          Box 7 -
     S   123456789                     123456789                           distribution X Distribution code         X8
         Box 15 - Payer’s Ohio number  Box 4 - Federal income tax withheld              Box 14 - Ohio tax withheld
         12345678                      123456789                                        12345678
  2. P/S Payer’s TIN                   Box 1 - Gross distribution
                                                                           Total          Box 7 -
     P   123456789                     123456789                           distribution X Distribution code         X8
         Box 15 - Payer’s Ohio number  Box 4 - Federal income tax withheld              Box 14 - Ohio tax withheld
         12345678                      123456789                                        12345678
  3. P/S Payer’s TIN                   Box 1 - Gross distribution
                                                                           Total          Box 7 -
     S   123456789                     123456789                           distribution X Distribution code         X8
         Box 15 - Payer’s Ohio number  Box 4 - Federal income tax withheld              Box 14 - Ohio tax withheld
         12345678                      123456789                                        12345678
  4. P/S Payer’s TIN                   Box 1 - Gross distribution
                                                                           Total          Box 7 -
     P   123456789                     123456789                           distribution X Distribution code         X8
         Box 15 - Payer’s Ohio number  Box 4 - Federal income tax withheld              Box 14 - Ohio tax withheld
         12345678                      123456789                                        12345678
  Part D - W-2Gs
  1. P/S Payer’s federal ID number     Box 1 - Reportable winnings               Box 4 - Federal income tax withheld
     S   123456789                     123456789                                 12345678
  
         Box 13 - Ohio state ID number Box 14 - Ohio state winnings                     Box 15 - Ohio income tax withheld
         12345678                      123456789                                        12345678
  2. P/S Payer’s federal ID number     Box 1 - Reportable winnings               Box 4 - Federal income tax withheld
     P   123456789                     123456789                                 12345678
         Box 13 - Ohio state ID number Box 14 - Ohio state winnings                     Box 15 - Ohio income tax withheld
         12345678                      123456789                                        12345678
  3. P/S Payer’s federal ID number     Box 1 - Reportable winnings               Box 4 - Federal income tax withheld
     S   123456789                     123456789                                 12345678
         Box 13 - Ohio state ID number Box 14 - Ohio state winnings                     Box 15 - Ohio income tax withheld
         12345678                      123456789                                        12345678
  Part E - 1099-NECs
  1. P/S Payer’s TIN                   Box 1 - Nonemployee compensation          Box 4 - Federal income tax withheld
     P   123456789                     123456789                                 12345678
         Box 6 - Payer’s Ohio number   Box 7 - State income                             Box 5 - Ohio tax withheld
         12345678                      123456789                                        12345678
  2. P/S Payer’s TIN                   Box 1 - Nonemployee compensation          Box 4 - Federal income tax withheld
     S   123456789                     123456789                                 12345678
         Box 6 - Payer’s Ohio number   Box 7 - State income                             Box 5 - Ohio tax withheld
         12345678                      123456789                                        12345678

                                                                           2023 Schedule of Withholding – page 2 of 2