2014 Ohio IT 1041P 
Federal Privacy Act Notice 
Because we require you to provide us with a Social Se-                                             Ohio Income Tax 
curity number, the       Federal Privacy Act of 1974 requires 
us to inform you that providing us with your Social Secu-                                          Payment Coupon for 
rity number is mandatory. Ohio Revised Code sections                                               Estates and Trusts 
5703.05, 5703.057 and 5747.08 authorize us to request 
this information. We need your Social Security number in 
order to administer this tax. 

                      Make your paper check or money order payable to Ohio Treasurer of State. Write 
                      the taxpayer identifi cation number on your paper check or money order and include  
                      Ohio form IT 1041P and your payment with Ohio form IT 1041. 

                               Please cut on the dotted line. DO NOT USE PENCIL to complete this form. 

OHIO IT 1041P                                  Rev. 7/14 
Ohio Income Tax Payment Coupon For                       Do NOT fold For Taxable Year Beginning In 
Estates and Trusts 
                                                         check         2014 
Federal Employer I.D. Number                             or coupon. 
                                                                     TRUST                                Check here for 
                                                                                                        amended return payment. 

Social Security Number of Decedent (estates only)                    ESTATE 

                                                                                Payment 
Name of trust or estate                                                         Amount             $        ,     ,                    . 0 0
Fiduciary name and title                                                        DO NOT STAPLE OR OTHERWISE ATTACH YOUR CHECK OR CHECK STUB  
                                                                                TO THIS COUPON. DO NOT SEND CASH. Return this coupon with check or 
                                                                                money order made payable to OHIO TREASURER OF STATEand mail to OHIO 
Number, street, P.O. Box, suite or room number                                  DEPARTMENT OF TAXATION, P.O. BOX 2619, COLUMBUS, OH  43216-2619. 
City, state, ZIP code 

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