PDF document
- 1 -
                                                          Rev. 09/21/22

Scan Specifications for the 

2022 Ohio IT 4738

Important Note

The following document (2022 Ohio IT 4738) contains grids for place-
ment of information on this specific tax form. To accurately print, do not 
reduce the size, rotate or center this document. Doing so jeopardizes 
the integrity of the grid. When printing from Adobe Reader, select 
“None” for “Page Scaling,” which is under “Page Handling.”

The 2022 Ohio IT 4738 test samples must be initially submitted 
by December 1, 2022 and approved no later than April 1, 2023. 

                        Ohio Department of Taxation

                        4485 Northland Ridge Blvd.

                        Columbus, OH 43229

                        tax.ohio.gov



- 2 -
General information 

regarding this form



- 3 -
    General Information (2022 Ohio IT 4738):

1) Dimensions: 
  
  Target or registration marks - 0.25” diameter circles. Follow grid layout for positioning.

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

  2D barcode (PDF 417) - See 2D instructions and schema. Follow grid layout for positioning. There is one 2D 
   barcode on each page of the Ohio IT 4738.

2) 1D barcode - The last two numbers of the 1D barcode represent the vendor number. Use the same vendor 
number as you did for last year’s return. If you have a question about your barcode assignment, e-mail the Forms 
Unit at Forms@tax.state.oh.us. The first six numbers are constant for this form (223901XX - 223907XX). 

  22 = tax year
  39 = Ohio IT 4738 
  01-07 = page number 
  XX = vendor number (assigned to you by the Ohio Dept. of Taxation, Forms Unit).

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

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

4) Use Courier font for the variable data fields on the form.

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

6) Do not use commas, hyphens or decimals in the variable data fields except where shown in specs.

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

8) The possible negative fields for this return are Schedule I, lines 1, 3, and 5 and Schedule II, lines 23, 27, 28d, 
28e, 29, 31 and 33. Do not hard-code negative signs.

9) Provide guidance to customers regarding duplex printing that instructs them to print pages 1 and 2 together; 
pages 3 and 4 together; and pages 5 and 6 together. Taxpayers have filed returns with pages 2 and 3 duplexed 
or a worksheet or software receipt on the back of a page of the return. This slows the processing of the tax return.

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

    10211411

11) The 4738 Schedule VI pages 5-7 can include up to 12 owners. Generate duplicate copies of page 7 to 
accommodate any additional owners, however omit the standard 1D and 2D barcodes from the duplicate pages 
and include the 10211411 barcode indicated above.



- 4 -
12) IMPORTANT NOTE: Add this statement to your software programs. It should print out with the taxpayer’s return. 
“Do not hand write in any corrections on the printed paper return. Hand writing in corrections will result 
in capturing incorrect data and delaying the processing of this income tax return. Make any corrections to 
this income tax return within [the software program name], then print and mail.”

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

14)*Important Note* Non-applicable lines must populate blank in the 2D barcode and show blank on the forms. 
Do not populate zero on the form or in the 2D barcode for non-applicable lines.

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



- 5 -
Additional instructions 

for the 2D barcode, 

              submissions, 

testing and notifications 

              Important Note

It is required that vendors program the Ohio IT 4708 to include 2D barcodes.



- 6 -
                                      2022 Ohio IT 4738

           Electing Pass-Through Entity Income Tax Return

                                2D Barcode Instructions
General Information
 •  The Ohio IT 4738 must be enabled for 2D barcode decoding
 A form enabled for 2D barcode should not allow users or practitioners the option to turn off/on the 2D barcode function
 •  The minimum error correction code level is 4
 •  Optimal dpi level is 300 dpi. The minimum dpi level is 200 dpi

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

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

     Examples of 2D Barcode data streams 
            Header Version Number T1<CR> 
            Developer Code 1111<CR> 
            Jurisdiction OH<CR>
            Description 2239<CR>
            Spec Version 0<CR> 
            Form Version 1<CR>
            Date Generated 011523<CR> 
            Line Item Specific Data IN<CR>
            Line Item Specific Data IT40<CR> 
            Line Item Specific Data 0<CR>
            Trailer *EOD* <CR>



- 7 -
Submission Process
   Test packets may be submitted by email to Forms@tax.state.oh.us
   The email subject line must include the vendor number, product name, tax year and form number in that order e.g. 12_
     ABCTax_ 22_4738
   Submissions must include
       One (1) full field sample in a PDF format
       Six (6) test scenarios for the Ohio IT 4738 provided by the Ohio Department of Taxation
           Each test scenario must be in a separate PDF using the following naming convention: vendor number, product name, 
             tax year, form number, test number e.g.12_ABCTax_22_4738_Test 1
       An emailed confirmation is sent to the vendor indicating the packet was received
       Submissions found to be missing any of the items above are rejected

Testing Process
   Testing of Ohio IT 4738 bundle packets commences on October 31, 2022 
   The deadline for an initial submission of Ohio IT 4738 bundle test packets is December 1, 2022 
   The deadline for approval of Ohio IT 4738 bundle test packets is April 18, 2023
   Test packets are reviewed in two (2) content areas- printed forms and 2D barcode data
   A submission is approved in its entirety once all sample documents pass in both areas
     Printed forms
           Vendor full field matches template provided in the specifications
           All fields are present, are formatted properly and align with grid layout
           Test scenarios contain values specified by Ohio Department of Taxation
     2D Barcode Data
           Barcodes read as valid
           All test scenarios can be decoded
           2D barcode data matches data on printed forms

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

         10211411

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



- 8 -
Grid layout



- 9 -
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85
2
3                                                              Do not staple or paper clip 
4
5                                                                                                      2022     Ohio IT 4738 
6                                                                            Rev. 08/04/22             Electing Pass-Through                                                                                         22390110
7
8                                                                                             Entity Income Tax Return
                                                          88 88 88
9
10                                                          Use only black ink and UPPERCASE letters. Use whole dollars only. If the amount on a line is negative, place a “-” in the box provided.
11                                                             Check here if amended return     Check here if final return                     Check here if federal                                                 Reporting Period Start Date
12                                                        X                                   X                                   X            extension filed
                                                                                                                                                                                                                                                       XX XX XX
13                                                        FEIN                                Entity Type:                      S corporation                                                             Partnership
14                                                                                            (check only one) X                                          X                                                          Reporting Period End Date
                                                          88 8888888
15                                                                                                             X                Limited liability company X                                               Other                                        XX XX XX
16                                                        Name of electing pass-through entity
17
18                                                        JOHNXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
19                                                        Address         Check here if address changed
                                                                 X
20
21                                                        8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
22                                                        City                                                                    State        ZIP code
23                                                                                                                                             88888
                                                          CITYXXXXXXXXXXXXXXXX                                                    OH
24
25                                                        Foreign State Code     Country Code Foreign country (if the mailing address is outside the U.S.)                                                                                             Foreign postal code
26
                                                          ABC                    AB           ANYCOUNTRYXXXXXXXXXX                                                                                                                                     AB88888
27
28                                                        Total number of owners Apportionment ratio, line 4                    Ohio charter or license no. (if S corp)
29
                                                          888888                 8.888888                                       88888888
30
31
32                                                        Questionnaire                                                                                                                                                  Yes   No 
33                                                        A.  S Corporations: Did the S corp pay compensation to any nonresident owners or members of an owner’s family? If YES, 
                                                          include a list of those individuals (including SSNs) and the amount of compensation paid.. ................................................
34                                                                                                                                                                                                                                                     X  X
35                                                        B.  Partnerships and LLCs: Did the Partnership or LLC make guaranteed payments to any nonresident owners or members 
36                                                        of an owner’s family? If YES, include a list of those individuals (with FEINs and SSNs) and the amount of guaranteed pay-
                             Do not staple or paper clip. 
37                                                        ment. ...................................................................................................................................................................................... X  X
38
39                                                        Schedule I – Taxable Income, Tax, Payments and Net Amount Due Calculations
40
41                                                          1.  Total business income (loss) (from line 33) .............................................................................. 1.         -              888888888888
42
43                                                          2.  Total business deductions (from line 39) .................................................................................. 2.                       888888888888
44
45                                                          3.  Net apportionable business income (line 1 minus line 2) ......................................................... 3.                  -              888888888888
46
47                                                          4.  Ohio apportionment ratio (from line 43) ................................................................................... 4.                            8.888888
48
49                                                          5.  Business income apportioned to Ohio (3 times line 4) ............................................................. 5.                 -              888888888888
50
                                                            6.  Net nonbusiness income allocated to Ohio (Include explanation and 
51                                                            supporting schedules.) ............................................................................................................. 6.                888888888888
52                                                          7.  Net nonbusiness loss allocated to Ohio (include explanation and 
53                                                            supporting schedules) .............................................................................................................. 7.                888888888888
54
55                                                          8.  Qualifying taxable income (sum of lines 5 and 6 minus line 7, if negative, enter zero) ............ 8.                                               888888888888
56
57
58
59
60                                                                                                                                                                                                      MM DD                                          YY CODE
61                                                                Software vendors: Place 2D barcode in this location
62                                                                Do not place a box around the 2D barcode. The box 
63                                                                               is only here for placement purposes.
                                                                                                                                               2022 IT 4738 – pg. 1 of 7
64
65
66



- 10 -
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85
2
3
4
5                                                         2022 IT 4738
6                            Rev. 08/04/22                                           FEIN                                                                     22390210
7
                                                              88 8888888
8
9  Schedule I – Taxable Income, Tax, Payments and Net Amount Due Calculations...cont.
10   9.  Tax liability  (see instructions for tax rate) .......................................................................................9.             888888888888
11
    
12 10. Interest penalty on underpayment of estimated tax (include Ohio IT/SD 2210) ............................10.                                            888888888888
13  
14   11.  Ohio IT 4738 estimated UPC/electronic payments for the taxable year .......................................11.                                      888888888888
15
   12. Ohio IT 1140 and IT 4708 estimated UPC/electronic payments claimed on 
16     this return (see instructions) ....................................................................................................................12. 888888888888
17
18 13. Refunds previously issued on the original IT 4738 (amended returns only) ..................................13.                                         888888888888
19
20 14. Total net Ohio estimated tax payments for 2022 (sum of lines 11 and 12 minus line 13) ..............14.                                                888888888888
21
22 15. Reserved .......................................................................................................................................15.
23
   16. Total Ohio tax payments (sum of lines 14 and 15) 
24     (Note:  No credits are allowed on the IT 4738) .........................................................................16.                            888888888888
25
26 17. Overpayment (line 16 minus sum of lines 9 and 10; if negative, enter zero).................................17.                                         888888888888
27   If line 17 is a positive amount, continue to line 18, OTHERWISE, continue to line 20.
28 18. Amount of line 17 to be CREDITED toward next year’s liability 
       (if this is an amended return, enter zero) .................................. CREDIT CARRYFORWARD
29                                                                                                         18.                                               888888888888
30
31 19. Amount of line 17 to be REFUNDED (line 17 minus line 18)....................................REFUND 19.                                                888888888888
32
33 20. Net amount due (sum of lines 9 and 10 minus line 16, if negative, enter zero) ....................................20.                                  888888888888
34
35   21. Interest due on late payment of tax (see instructions) ..................................................................21.                         888888888888
36   22. Total amount due (add lines 20 and 21). Make check payable to Ohio Treasurer of State, 
37     include Ohio IT 4738 UPC and place FEIN on check  .....................................AMOUNT DUE22.                                                  888888888888
38
39         If your refund is $1.00 or less, no refund will be issued. If you owe $1.00 or less, no payment is necessary.
40
41 Sign Here (required): I represent and understand  that the filing of this return is an irrevocable 
   election to be subject to the tax levied under R.C. 5747.38 for the taxable year. I have read this                                                         Do not staple or paper clip. 
42 return. Under penalties of perjury, I declare that, to the best of my knowledge and belief, the return                                                 Place any supporting documents, including 
43 and all enclosures are true, correct and complete.                                                      Ohio IT K-1s, after the last page of this return.
44
                                                                                                                                                                               
45 Electing pass-through entity officer or agent (print)  
                                                                                                                                                              Mail to: 
46
47 Title of officer or agent (print)                                                      Phone number                                                        Ohio Dept. of Taxation
48                                                                                                                                                            P.O. Box 181140
49 Signature of electing pass-through entity officer or agent                             Date (MM/DD/YY)                                                     Columbus, OH 43218-1140

50 Preparer’s name (print)                                                                Phone number
51
                                                                                                                                                               Instructions for this form are 
52 Preparer’s e-mail address                                               PTIN      P    88888888                                                            available at tax.ohio.gov
53
54 Check here if you authorize your preparer to contact us regarding this return          X
55
56
57
58
59
60
61         Software vendors: Place 2D barcode in this location
62         Do not place a box around the 2D barcode. The box 
63                                   is only here for placement purposes.
                                                                                                       2022 IT 4738 – pg. 2 of 7
64
65
66



- 11 -
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85
2
3
4
5                                                          2022 IT 4738
6                         Rev. 08/04/22                                       FEIN
                                                                                                                                                              22390310
7
                                                                   88 8888888
8  Schedule II – Income and Adjustments
9  Amounts reflected in Schedule II and Schedule III are the combined amounts from the federal Schedule K-1s for the taxable year for all owners.                     Include 
10 with this return a copy of the applicable federal 1120S or 1065 and K-1s of all owners.
11                                                                                                                                                          -
   23. Ordinary business income (loss) ...................................................................................................23.                 888888888888
12
13
   24. Related member adjustments for expenses or losses incurred by the electing pass-through entity ........24.                                             888888888888
14
15 25. Guaranteed payments that the electing pass-through entity made to each owner if such  
         owner directly or indirectly owns at least 20% of the electing pass-through entity ......................25. 
16                                                                                                                                                            888888888888
17 26. Compensation that the electing pass-through entity paid to each owner if such owner  
18       directly or indirectly owns at least 20% of the electing pass-through entity. Reciprocity  
         agreements do not apply ...............................................................................................................26.
19                                                                                                                                                            888888888888
20
   27. Net income (loss) from rental activities other than amount shown on line 23 ...............................27.
21                                                                                                                                                          - 888888888888
22
     28a  Interest income .......................................................................................................................... 28a.
23                                                                                                                                                            888888888888
24  
     28b  Dividends ...................................................................................................................................28b.
25                                                                                                                                                            888888888888
    
26
     28c Royalties .....................................................................................................................................28c.
27                                                                                                                                                            888888888888

28   28d Net short-term capital gain (loss)................................................................................................28d.             - 888888888888
29
30   28e Net long-term capital gain (loss). Exclude from this line any capital loss carryforward amount. Note: If 
       adding lines 28d and 28e results in a net loss, the net allowable loss for the sum of these two lines 
31      cannot exceed the product of $3,000 and the number of owners ...........................................................28e.-                         888888888888
32
33 29. Net gain (loss) under IRC § section 1231 .....................................................................................29.                    - 888888888888
34   30. IRC §168(k) bonus depreciation and §179 expense add-back.
35     Complete Schedule VI ..................................................................................................................30.
36                                                                                                                                                            888888888888
                2/3                5/6              6/6 (check applicable box)
37       X            X               X  
38
   31. Other income or deduction and federal conformity additions (include explanation and 
39     supporting schedule) .....................................................................................................................31.        -
40                                                                                                                                                            888888888888
41 32. Reserved .......................................................................................................................................32.
42
43 33. Total business income (loss)(add lines 23-32; enter here and on line 1) ......................................33.                                    -
44                                                                                                                                                            888888888888
   Schedule III – Deductions
45 List only those deductions that have not already been used to reduce any income items included on 
46 Schedule II. 
47   34. IRC § 179 expense not deducted in calculating line 23 ................................................................34.                            888888888888
48   35. Deduction of prior year IRC §168(k) bonus depreciation and §179 expense add-backs 
49     (complete Schedule V) ..................................................................................................................35.            888888888888
50
    
51 36. Net federal interest/dividends exempt from state taxation & federal conformity adjustments .......36.                                                  888888888888
52  
53 37. Exempt gains from the sale of Ohio state or local government bonds ..........................................37.                                       888888888888
54
    
55   38. Reserved .......................................................................................................................................38.
56
57 39. Total business deductions (add lines 34-38; enter here and on line 2) .........................................39.                                     888888888888
58
59
60
61                    Software vendors: Place 2D barcode in this location
62                    Do not place a box around the 2D barcode. The box 
63                        is only here for placement purposes.
                                                                                                         2022 IT 4738 – pg. 3 of 7
64
65
66



- 12 -
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85
2
3
4
5                                                            2022 IT 4738
6                               Rev. 08/04/22                          FEIN                                                             22390410
7
                                                                  88 8888888
8
   Schedule IV – Apportionment Worksheet
9  Use this schedule to calculate the apportionment ratio for a electing pass-through entity that is not a financial institution. Financial institutions should refer
10 to the instructions. Note: Carry all ratios to six decimal places.
11 40.  Property                                              Within Ohio                                                  Total Everywhere
12
                                                             888888888888                                                  888888888888
13      a) Owned (original cost)          
14                                                            Within Ohio                                                  Total Everywhere
    
15
16       b) Rented (annual rental X 8)                       888888888888                                                  888888888888
17                                                            Within Ohio                                                  Total Everywhere
18                                                           888888888888        ÷                                         888888888888
19      c) Total (lines 40a and 40b)
20                                                                     Ratio        Weight                                              Weighted Ratio
                                                                                  x 
21                                                            =        8.888888     8.88                                     =          8.888888
22
23                                                            Within Ohio                                                  Total Everywhere
                                                                                 ÷
24                                                           888888888888                                                  888888888888
25   41.  Payroll
26                                                                     Ratio        Weight                                              Weighted Ratio
                                                              =                   x 
27                                                                     8.888888     8.88                                     =          8.888888
28
29                                                            Within Ohio                                                  Total Everywhere
30   42.  Sales                                              888888888888        ÷                                         888888888888
31
32                                                                     Ratio        Weight                                              Weighted Ratio
33                                                            =        8.888888   x 8.88                                     =          8.888888
34
35   43.  Ohio apportionment ratio (add lines 40c, 41 and 42). Enter ratio here and on line 4 ......................................43. 8.888888
36
37   Note: If the “Total Everywhere” of any factor is zero, the weight given to the other factors must be proportionately increased so that the total weight 
38   given to the combined number of factors used is 100%, i.e., if no property/payroll, use 25% and 75%; if no sales, use 50% property/payroll; if only 
39   one factor, use 100%.
40
   Schedule V – IRC § 168K Bonus Depreciation and §179 Expense Add-back Schedule
41
42   X Check the box if partial or full depreciation add-back has been waived.
43
44 44. Current year IRC §168(k) bonus depreciation and §179 expense add-back ..........................................44. 888888888888
45
46 45. Prior years add-back amount and applicable add-back ratio
47   
                                                             Column (A) – Amount    Column (B) – Ratio
48
49         45a. Year Prior.................................. 888888888888          X 2/3                X                               5/6                  X   6/6
50          

51         45b. 2 Years Prior .............................  888888888888          X 2/3                X                               5/6                  X   6/6
52
53         45c. 3 Years Prior .............................  888888888888          X 2/3                X                               5/6                  X   6/6
54
55         45d. 4 Years Prior .............................  888888888888          X 2/3                X                               5/6                  X   6/6
56
57         45e. 5 Years Prior .............................. 888888888888          X 2/3                X                               5/6                  X   6/6
58
59
60
61                      Software vendors: Place 2D barcode in this location
62                      Do not place a box around the 2D barcode. The box 
63                              is only here for placement purposes.
                                                                                 2022 IT 4738 – pg. 4 of 7
64
65
66



- 13 -
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85
2
3
4
5                                       2022 IT 4738
6                    Rev. 08/04/22             FEIN                                                             22390510
7
                                        88 8888888
8  Schedule VI – Owner Information
9  List all owners in order from highest to lowest ownership percentage.  Use an additional sheet, if necessary.
10 SSN                             FEIN                  Percent of ownership                                   Share of EPTE tax (tax credit)
11
12 888 88 8888                     88 8888888            8.8888                                                 888888888
13 First name/entity                    M.I.   Last name
14                                             PUBLICXXXXXXXXXXXXXX
   JOHNXXXXXXXXXXX                      Q
15
16 Address
17
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
18
19 City                                                  State ZIP code
20                                                             88888
   CITYXXXXXXXXXXXXXXXX                                  OH
21
22 SSN                             FEIN                  Percent of ownership                                   Share of EPTE tax (tax credit)
23
24 888 88 8888                     88 8888888            8.8888                                                 888888888
25 First name/entity                    M.I.   Last name
26                                             PUBLICXXXXXXXXXXXXXX
   JOHNXXXXXXXXXXX                      Q
27
28 Address
29
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
30
31 City                                                  State ZIP code
32                                                             88888
   CITYXXXXXXXXXXXXXXXX                                  OH
33
34 SSN                             FEIN                  Percent of ownership                                   Share of EPTE tax (tax credit)
35
36 888 88 8888                     88 8888888            8.8888                                                 888888888
37 First name/entity                    M.I.   Last name
38                                             PUBLICXXXXXXXXXXXXXX
   JOHNXXXXXXXXXXX                      Q
39
40 Address
41
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
42
43 City                                                  State ZIP code
44                                                             88888
   CITYXXXXXXXXXXXXXXXX                                  OH
45
46 SSN                             FEIN                  Percent of ownership                                   Share of EPTE tax (tax credit)
47
48 888 88 8888                     88 8888888            8.8888                                                 888888888
49 First name/entity                    M.I.   Last name
50                                             PUBLICXXXXXXXXXXXXXX
   JOHNXXXXXXXXXXX                      Q
51
52 Address
53
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
54
55 City                                                  State ZIP code
56                                                             88888
   CITYXXXXXXXXXXXXXXXX                                  OH
57
58
59
60
61        Software vendors: Place 2D barcode in this location
62        Do not place a box around the 2D barcode. The box 
63                   is only here for placement purposes.
                                                               2022 IT 4738 – pg. 5 of 7
64
65
66



- 14 -
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85
2
3
4
5                                         2022 IT 4738
6                    Rev. 08/04/22             FEIN                           22390610
7
                                          88 8888888
8
9  Schedule VI – Owner Information...cont.
10 SSN                             FEIN                  Percent of ownership Share of EPTE tax (tax credit)
11
12 888 88 8888                     88 8888888            8.8888               888888888
13 First name/entity                      M.I. Last name
14                                             PUBLICXXXXXXXXXXXXXX
   JOHNXXXXXXXXXXX                        Q
15
16 Address
17
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
18
19 City                                                  State ZIP code
20                                                             88888
   CITYXXXXXXXXXXXXXXXX                                  OH
21
22 SSN                             FEIN                  Percent of ownership Share of EPTE tax (tax credit)
23
24 888 88 8888                     88 8888888            8.8888               888888888
25 First name/entity                      M.I. Last name
26                                             PUBLICXXXXXXXXXXXXXX
   JOHNXXXXXXXXXXX                        Q
27
28 Address
29
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
30
31 City                                                  State ZIP code
32                                                             88888
   CITYXXXXXXXXXXXXXXXX                                  OH
33
34 SSN                             FEIN                  Percent of ownership Share of EPTE tax (tax credit)
35
36 888 88 8888                     88 8888888            8.8888               888888888
37 First name/entity                      M.I. Last name
38                                             PUBLICXXXXXXXXXXXXXX
   JOHNXXXXXXXXXXX                        Q
39
40 Address
41
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
42
43 City                                                  State ZIP code
44                                                             88888
   CITYXXXXXXXXXXXXXXXX                                  OH
45
46 SSN                             FEIN                  Percent of ownership Share of EPTE tax (tax credit)
47
48 888 88 8888                     88 8888888            8.8888               888888888
49 First name/entity                      M.I. Last name
50                                             PUBLICXXXXXXXXXXXXXX
   JOHNXXXXXXXXXXX                        Q
51
52 Address
53
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
54
55 City                                                  State ZIP code
56                                                             88888
   CITYXXXXXXXXXXXXXXXX                                  OH
57
58
59
60
61        Software vendors: Place 2D barcode in this location
62        Do not place a box around the 2D barcode. The box 
63                   is only here for placement purposes.
                                                               2022 IT 4738 – pg. 6 of 7
64
65
66



- 15 -
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85
2
3
4
5                                         2022 IT 4738
6                    Rev. 08/04/22             FEIN                           22390710
7
                                          88 8888888
8
9  Schedule VI – Owner Information...cont.
10 SSN                             FEIN                  Percent of ownership Share of EPTE tax (tax credit)
11
12 888 88 8888                     88 8888888            8.8888               888888888
13 First name/entity                      M.I. Last name
14                                             PUBLICXXXXXXXXXXXXXX
   JOHNXXXXXXXXXXX                        Q
15
16 Address
17
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
18
19 City                                                  State ZIP code
20                                                             88888
   CITYXXXXXXXXXXXXXXXX                                  OH
21
22 SSN                             FEIN                  Percent of ownership Share of EPTE tax (tax credit)
23
24 888 88 8888                     88 8888888            8.8888               888888888
25 First name/entity                      M.I. Last name
26                                             PUBLICXXXXXXXXXXXXXX
   JOHNXXXXXXXXXXX                        Q
27
28 Address
29
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
30
31 City                                                  State ZIP code
32                                                             88888
   CITYXXXXXXXXXXXXXXXX                                  OH
33
34 SSN                             FEIN                  Percent of ownership Share of EPTE tax (tax credit)
35
36 888 88 8888                     88 8888888            8.8888               888888888
37 First name/entity                      M.I. Last name
38                                             PUBLICXXXXXXXXXXXXXX
   JOHNXXXXXXXXXXX                        Q
39
40 Address
41
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
42
43 City                                                  State ZIP code
44                                                             88888
   CITYXXXXXXXXXXXXXXXX                                  OH
45
46 SSN                             FEIN                  Percent of ownership Share of EPTE tax (tax credit)
47
48 888 88 8888                     88 8888888            8.8888               888888888
49 First name/entity                      M.I. Last name
50                                             PUBLICXXXXXXXXXXXXXX
   JOHNXXXXXXXXXXX                        Q
51
52 Address
53
   8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
54
55 City                                                  State ZIP code
56                                                             88888
   CITYXXXXXXXXXXXXXXXX                                  OH
57
58
59
60
61        Software vendors: Place 2D barcode in this location
62        Do not place a box around the 2D barcode. The box 
63                   is only here for placement purposes.
                                                               2022 IT 4738 – pg. 7 of 7
64
65
66



- 16 -
Layout 

without grid



- 17 -
Do not staple or paper clip 

2022     Ohio IT 4738 
Rev. 08/04/22 Electing Pass-Through 22390110
88 88 88 Entity Income Tax Return

Use only black ink and UPPERCASE letters. Use whole dollars only. If the amount on a line is negative, place a “-” in the box provided.
Check here if amended return Check here if final return Check here if federal Reporting Period Start Date
X X X extension filed
XX XX XX
FEIN Entity Type: S corporation   Partnership
(check only one) X X Reporting Period End Date
88 8888888
Limited liability company   Other
Name of electing pass-through entity X X XX XX XX

JOHNXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Address         Check here if address changed
X
8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX
City State ZIP code
CITYXXXXXXXXXXXXXXXX OH 88888
Foreign State Code Country Code Foreign country (if the mailing address is outside the U.S.) Foreign postal code
ABC AB ANYCOUNTRYXXXXXXXXXX AB88888
Total number of owners Apportionment ratio, line 4 Ohio charter or license no. (if S corp)
888888 8.888888 88888888

Questionnaire     Yes   No 
A.  S Corporations: Did the S corp pay compensation to any nonresident owners or members of an owner’s family? If YES, 
include a list of those individuals (including SSNs) and the amount of compensation paid.. ................................................ X X
B.  Partnerships and LLCs: Did the Partnership or LLC make guaranteed payments to any nonresident owners or members 
of an owner’s family? If YES, include a list of those individuals (with FEINs and SSNs) and the amount of guaranteed pay-
Do not staple or paper clip. 
ment. ...................................................................................................................................................................................... X X

Schedule I – Taxable Income, Tax, Payments and Net Amount Due Calculations

  1.  Total business income (loss) (from line 33) .............................................................................. 1. - 888888888888

  2.  Total business deductions (from line 39) .................................................................................. 2. 888888888888

  3.  Net apportionable business income (line 1 minus line 2) ......................................................... 3. - 888888888888

  4.  Ohio apportionment ratio (from line 43) ................................................................................... 4.      8.888888

  5.  Business income apportioned to Ohio (3 times line 4) ............................................................. 5. - 888888888888
  6.  Net nonbusiness income allocated to Ohio (Include explanation and 
    supporting schedules.) ............................................................................................................. 6. 888888888888
  7.  Net nonbusiness loss allocated to Ohio (include explanation and 
    supporting schedules) .............................................................................................................. 7. 888888888888

  8.  Qualifying taxable income (sum of lines 5 and 6 minus line 7, if negative, enter zero) ............ 8. 888888888888

MM DD YY CODE
Software vendors: Place 2D barcode in this location
Do not place a box around the 2D barcode. The box 
is only here for placement purposes.
2022 IT 4738 – pg. 1 of 7



- 18 -
                                                       2022 IT 4738
                          Rev. 08/04/22                                           FEIN                                                                     22390210
                                                           88 8888888

Schedule I – Taxable Income, Tax, Payments and Net Amount Due Calculations...cont.
  9.  Tax liability  (see instructions for tax rate) .......................................................................................9.             888888888888
 
10. Interest penalty on underpayment of estimated tax (include Ohio IT/SD 2210) ............................10.                                            888888888888
 
  11.  Ohio IT 4738 estimated UPC/electronic payments for the taxable year .......................................11.                                      888888888888
12. Ohio IT 1140 and IT 4708 estimated UPC/electronic payments claimed on 
    this return (see instructions) ....................................................................................................................12. 888888888888

13. Refunds previously issued on the original IT 4738 (amended returns only) ..................................13.                                         888888888888

14. Total net Ohio estimated tax payments for 2022 (sum of lines 11 and 12 minus line 13) ..............14.                                                888888888888

15. Reserved .......................................................................................................................................15.
16. Total Ohio tax payments (sum of lines 14 and 15) 
    (Note:  No credits are allowed on the IT 4738) .........................................................................16.                            888888888888

17. Overpayment (line 16 minus sum of lines 9 and 10; if negative, enter zero).................................17.                                         888888888888
  If line 17 is a positive amount, continue to line 18, OTHERWISE, continue to line 20.
18. Amount of line 17 to be CREDITED toward next year’s liability 
    (if this is an amended return, enter zero) .................................. CREDIT CARRYFORWARD 18.                                                 888888888888

19. Amount of line 17 to be REFUNDED (line 17 minus line 18)....................................REFUND 19.                                                888888888888

20. Net amount due (sum of lines 9 and 10 minus line 16, if negative, enter zero) ....................................20.                                  888888888888

  21. Interest due on late payment of tax (see instructions) ..................................................................21.                         888888888888
  22. Total amount due (add lines 20 and 21). Make check payable to Ohio Treasurer of State, 
    include Ohio IT 4738 UPC and place FEIN on check  .....................................AMOUNT DUE22.                                                  888888888888

        If your refund is $1.00 or less, no refund will be issued. If you owe $1.00 or less, no payment is necessary.
Sign Here (required): I represent and understand  that the filing of this return is an irrevocable 
election to be subject to the tax levied under R.C. 5747.38 for the taxable year. I have read this                                                         Do not staple or paper clip. 
return. Under penalties of perjury, I declare that, to the best of my knowledge and belief, the return                                                 Place any supporting documents, including 
and all enclosures are true, correct and complete.                                                     Ohio IT K-1s, after the last page of this return.
                                                                                                                                                                           
Electing pass-through entity officer or agent (print)  
                                                                                                                                                           Mail to: 
Title of officer or agent (print)                                                      Phone number                                                        Ohio Dept. of Taxation
                                                                                                                                                           P.O. Box 181140
Signature of electing pass-through entity officer or agent                             Date (MM/DD/YY)                                                     Columbus, OH 43218-1140

Preparer’s name (print)                                                                Phone number
                                                                                                                                                            Instructions for this form are 
Preparer’s e-mail address                                               PTIN      P    88888888                                                            available at tax.ohio.gov

Check here if you authorize your preparer to contact us regarding this return          X

        Software vendors: Place 2D barcode in this location
        Do not place a box around the 2D barcode. The box 
                                  is only here for placement purposes.
                                                                                                    2022 IT 4738 – pg. 2 of 7



- 19 -
                                                                           2022 IT 4738
                                  Rev. 08/04/22                                FEIN
                                                                                                                                                            22390310
                                                                               88 8888888
Schedule II – Income and Adjustments
Amounts reflected in Schedule II and Schedule III are the combined amounts from the federal Schedule K-1s for the taxable year for all owners.                      Include 
with this return a copy of the applicable federal 1120S or 1065 and K-1s of all owners.
23. Ordinary business income (loss) ...................................................................................................23.                - 888888888888

24. Related member adjustments for expenses or losses incurred by the electing pass-through entity ........24.                                              888888888888
25. Guaranteed payments that the electing pass-through entity made to each owner if such  
      owner directly or indirectly owns at least 20% of the electing pass-through entity ......................25.                                          888888888888
26. Compensation that the electing pass-through entity paid to each owner if such owner  
      directly or indirectly owns at least 20% of the electing pass-through entity. Reciprocity  
      agreements do not apply ...............................................................................................................26.            888888888888

27. Net income (loss) from rental activities other than amount shown on line 23 ...............................27.                                        - 888888888888

   28a  Interest income .......................................................................................................................... 28a.     888888888888
 
  28b  Dividends ...................................................................................................................................28b.    888888888888
 
  28c Royalties .....................................................................................................................................28c.   888888888888

  28d Net short-term capital gain (loss)................................................................................................28d.              - 888888888888
  28e Net long-term capital gain (loss). Exclude from this line any capital loss carryforward amount. Note: If 
    adding lines 28d and 28e results in a net loss, the net allowable loss for the sum of these two lines 
     cannot exceed the product of $3,000 and the number of owners ...........................................................28e.-                          888888888888

29. Net gain (loss) under IRC § section 1231 .....................................................................................29.                     - 888888888888
  30. IRC §168(k) bonus depreciation and §179 expense add-back.
    Complete Schedule VI ..................................................................................................................30.
                                                                                                                                                            888888888888
        X    2/3               X  5/6             X  6/6 (check applicable box)

31. Other income or deduction and federal conformity additions (include explanation and 
    supporting schedule) .....................................................................................................................31.         -
                                                                                                                                                            888888888888
32. Reserved .......................................................................................................................................32.

33. Total business income (loss)(add lines 23-32; enter here and on line 1) ......................................33.                                     -
                                                                                                                                                            888888888888
Schedule III – Deductions
List only those deductions that have not already been used to reduce any income items included on 
Schedule II. 
  34. IRC § 179 expense not deducted in calculating line 23 ................................................................34.                             888888888888
  35. Deduction of prior year IRC §168(k) bonus depreciation and §179 expense add-backs 
    (complete Schedule V) ..................................................................................................................35.             888888888888
 
36. Net federal interest/dividends exempt from state taxation & federal conformity adjustments .......36.                                                   888888888888
 
37. Exempt gains from the sale of Ohio state or local government bonds ..........................................37.                                        888888888888
 
  38. Reserved .......................................................................................................................................38.

39. Total business deductions (add lines 34-38; enter here and on line 2) .........................................39.                                      888888888888

                   Software vendors: Place 2D barcode in this location
                   Do not place a box around the 2D barcode. The box 
                                  is only here for placement purposes.
                                                                                                      2022 IT 4738 – pg. 3 of 7



- 20 -
                                                          2022 IT 4738
                             Rev. 08/04/22                          FEIN                                                             22390410
                                                               88 8888888
Schedule IV – Apportionment Worksheet
Use this schedule to calculate the apportionment ratio for a electing pass-through entity that is not a financial institution. Financial institutions should refer
to the instructions. Note: Carry all ratios to six decimal places.
40.  Property                                              Within Ohio                                                  Total Everywhere
                                                          888888888888                                                  888888888888
     a) Owned (original cost)          
                                                           Within Ohio                                                  Total Everywhere
      b) Rented (annual rental X 8)                       888888888888                                                  888888888888
                                                           Within Ohio                                                  Total Everywhere
                                                                              ÷
     c) Total (lines 40a and 40b)                         888888888888                                                  888888888888
                                                                    Ratio        Weight                                              Weighted Ratio
                                                           =        8.888888   x 8.88                                     =          8.888888
                                                           Within Ohio                                                  Total Everywhere
                                                          888888888888        ÷                                         888888888888
  41.  Payroll
                                                                    Ratio        Weight                                              Weighted Ratio
                                                           =        8.888888   x 8.88                                     =          8.888888
                                                           Within Ohio                                                  Total Everywhere
  42.  Sales                                              888888888888        ÷                                         888888888888

                                                                    Ratio        Weight                                              Weighted Ratio
                                                           =        8.888888   x 8.88                                     =          8.888888

  43.  Ohio apportionment ratio (add lines 40c, 41 and 42). Enter ratio here and on line 4 ......................................43. 8.888888

  Note: If the “Total Everywhere” of any factor is zero, the weight given to the other factors must be proportionately increased so that the total weight 
  given to the combined number of factors used is 100%, i.e., if no property/payroll, use 25% and 75%; if no sales, use 50% property/payroll; if only 
  one factor, use 100%.

Schedule V – IRC § 168K Bonus Depreciation and §179 Expense Add-back Schedule

  X Check the box if partial or full depreciation add-back has been waived.

44. Current year IRC §168(k) bonus depreciation and §179 expense add-back ..........................................44. 888888888888
45. Prior years add-back amount and applicable add-back ratio
  
                                                          Column (A) – Amount    Column (B) – Ratio

        45a. Year Prior.................................. 888888888888          X 2/3                X                               5/6                  X   6/6
         
        45b. 2 Years Prior .............................  888888888888          X 2/3                X                               5/6                  X   6/6

        45c. 3 Years Prior .............................  888888888888          X 2/3                X                               5/6                  X   6/6

        45d. 4 Years Prior .............................  888888888888          X 2/3                X                               5/6                  X   6/6

        45e. 5 Years Prior .............................. 888888888888          X 2/3                X                               5/6                  X   6/6

                     Software vendors: Place 2D barcode in this location
                     Do not place a box around the 2D barcode. The box 
                             is only here for placement purposes.
                                                                              2022 IT 4738 – pg. 4 of 7



- 21 -
                                     2022 IT 4738
                  Rev. 08/04/22            FEIN                                                              22390510
                                     88 8888888
Schedule VI – Owner Information
List all owners in order from highest to lowest ownership percentage.  Use an additional sheet, if necessary.
SSN                             FEIN                  Percent of ownership                                   Share of EPTE tax (tax credit)
888 88 8888                     88 8888888            8.8888                                                 888888888
First name/entity                    M.I.  Last name
JOHNXXXXXXXXXXX                      Q     PUBLICXXXXXXXXXXXXXX
Address
8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX

City                                                  State ZIP code
CITYXXXXXXXXXXXXXXXX                                  OH    88888

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

SSN                             FEIN                  Percent of ownership                                   Share of EPTE tax (tax credit)
888 88 8888                     88 8888888            8.8888                                                 888888888
First name/entity                    M.I.  Last name
JOHNXXXXXXXXXXX                      Q     PUBLICXXXXXXXXXXXXXX
Address
8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX

City                                                  State ZIP code
CITYXXXXXXXXXXXXXXXX                                  OH    88888

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

       Software vendors: Place 2D barcode in this location
       Do not place a box around the 2D barcode. The box 
                  is only here for placement purposes.
                                                            2022 IT 4738 – pg. 5 of 7



- 22 -
                                       2022 IT 4738
                  Rev. 08/04/22             FEIN                           22390610
                                       88 8888888
Schedule VI – Owner Information...cont.
SSN                             FEIN                  Percent of ownership Share of EPTE tax (tax credit)
888 88 8888                     88 8888888            8.8888               888888888
First name/entity                      M.I. Last name
JOHNXXXXXXXXXXX                        Q    PUBLICXXXXXXXXXXXXXX
Address
8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX

City                                                  State ZIP code
CITYXXXXXXXXXXXXXXXX                                  OH    88888

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

SSN                             FEIN                  Percent of ownership Share of EPTE tax (tax credit)
888 88 8888                     88 8888888            8.8888               888888888
First name/entity                      M.I. Last name
JOHNXXXXXXXXXXX                        Q    PUBLICXXXXXXXXXXXXXX
Address
8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX

City                                                  State ZIP code
CITYXXXXXXXXXXXXXXXX                                  OH    88888

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

       Software vendors: Place 2D barcode in this location
       Do not place a box around the 2D barcode. The box 
                  is only here for placement purposes.
                                                            2022 IT 4738 – pg. 6 of 7



- 23 -
                                       2022 IT 4738
                  Rev. 08/04/22             FEIN                           22390710
                                       88 8888888
Schedule VI – Owner Information...cont.
SSN                             FEIN                  Percent of ownership Share of EPTE tax (tax credit)
888 88 8888                     88 8888888            8.8888               888888888
First name/entity                      M.I. Last name
JOHNXXXXXXXXXXX                        Q    PUBLICXXXXXXXXXXXXXX
Address
8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX

City                                                  State ZIP code
CITYXXXXXXXXXXXXXXXX                                  OH    88888

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

SSN                             FEIN                  Percent of ownership Share of EPTE tax (tax credit)
888 88 8888                     88 8888888            8.8888               888888888
First name/entity                      M.I. Last name
JOHNXXXXXXXXXXX                        Q    PUBLICXXXXXXXXXXXXXX
Address
8888 CHERRY LANEXXXXXXXXXXXXXXXXXXX

City                                                  State ZIP code
CITYXXXXXXXXXXXXXXXX                                  OH    88888

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

       Software vendors: Place 2D barcode in this location
       Do not place a box around the 2D barcode. The box 
                  is only here for placement purposes.
                                                            2022 IT 4738 – pg. 7 of 7






PDF file checksum: 3817928698

(Plugin #1/9.12/13.0)