2015 SD 101 Long Rev. 11/14
School District Income Tax Employer’s Payment of School
P.O. Box 182388 Columbus, OH 43218-2388 15070100 District Income Tax Withheld
Ohio withholding acct. no. FEIN Payment due date For the period ending
Name
For State Use Only
Number and street M D D YM Y
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District District District District
District Name Number Tax Due District Name Number Tax Due
Ada EVSD 3301 Columbus Grove LSD 6901
Amanda-Clearcreek LSD 2301 Continental LSD 6902
Anna LSD 7501 Cory-Rawson LSD 3203
Ansonia LSD 1901 Covington EVSD 5503
Antwerp LSD 6301 Crestline EVSD 1704
Arcadia LSD 3201 Crestview LSD 1503
Arcanum-Butler LSD 1902 Crestview LSD 8101
Arlington LSD 3202 Dalton LSD 8502
Athens CSD 0502 Danville LSD 4202
Ayersville LSD 2001 Defi ance CSD 2003
Bellevue CSD 3901 Eastwood LSD 8702
Berkshire LSD 2801 Eaton CSD 6803
Berne-Union LSD 2302 Edgerton LSD 8602
Bethel LSD 5501 Elgin LSD 5101
Bexley CSD 2501 Elmwood LSD 8703
Big Walnut LSD 2101 Evergreen LSD 2602
Bloom-Carroll LSD 2303 Fairbanks LSD 8001
Bluffton EVSD 0203 Fairborn CSD 2903
Botkins LSD 7502 Fairfi eld Union LSD 2304
Bowling Green CSD 8701 Fairlawn LSD 7503
Bradford EVSD 5502 Fort Loramie LSD 7504
Bryan CSD 8601 Fort Recovery LSD 5406
Buckeye Central LSD 1701 Franklin Monroe LSD 1903
Buckeye Valley LSD 2102 Fremont CSD 7202
Canal Winchester LSD 2502 Gibsonburg EVSD 7203
Cardington-Lincoln LSD 5901 Gorham Fayette LSD 2603
Carey EVSD 8801 Goshen LSD 1305
Carlisle LSD 8301 Greeneview LSD 2904
Cedar Cliff LSD 2902 Greenfi eld EVSD 3603
Celina CSD 5401 Greenville CSD 1904
Centerburg LSD 4201 Hardin-Houston LSD 7505
Central LSD 2002 Hardin Northern LSD 3302
Chippewa LSD 8501 Hicksville EVSD 2004
Circleville CSD 6501 Highland LSD 5902
Clear Fork Valley LSD 7001 Hillsboro CSD 3604
Clermont-Northeastern LSD 1303 Hillsdale LSD 0302
Cloverleaf LSD 5204 Holgate LSD 3501
Clyde-Green Springs EVSD 7201 Hopewell-Loudon LSD 7403
Coldwater EVSD 5402 Jackson Center LSD 7506
Colonel Crawford LSD 1703 Subtotal from page 2
Columbiana EVSD 1502 Total tax due
DO NOT STAPLE OR OTHERWISE ATTACH YOUR CHECK I declare under penalties of perjury that this return, including any accompanying schedules and
ORMakeCHECKcheckSTUBpayableTOto SCHOOLTHIS FORM.DISTRICTDO NOTINCOMESEND CASH.TAXand statements, has been examined by me and, to the best of my knowledge and belief, is a true,
mail to School District Income Tax, P.O. Box 182388, Columbus, correct and complete return and report.
OH 43218-2388.
Signature Title Date