CHECK ALL THAT APPLY:  Individual        Proprietor      Partner/Partnership  Corporation  S Corp    LLC Amended Return            1 sttime filer REFUND 

MAKE CHECK OR MONEY ORDER TO:                                                                            Primary SSN or
CITY OF ASHTABULA  –TAX DEPT                           INCOME TAX RETURN                                 Federal ID 
4717 MAIN AVE., STE. A                                             2022  
ASHTABULA, OHIO 44004                                                                                    Spouse SSN 
Phone: (440) 992-7104 Fax: (440) 992-7556
Email: incometax@cityofashtabula.com                     DUE DATE APRIL 18,        2023                  Phone No. 
Name:                                                                                                    Email Address:
Spouse Name:                                                                                             MOVE IN       OUT              DATE:
Address:                                                                                                           (Fill in circle)
                                                                                                         FORWARDING OR NEW ADDRESS: 
                                                                   FILE# 

RETIRED AND TAXPAYERS WITH NO TAXABLE INCOME:  REASON  (CHECK APPROPRIATE BOX TO INACTIVATE ACCOUNT) 
     ACTIVE DUTY MILITARY                            RETIRED WITH ONLY NON-TAXABLE INCOME         RETIREMENT DATE 
     TAXPAYER DECEASED                               ONLY INCOME FROM NON-TAXABLE SOURCE; LIST SOURCE 
STOP HERE: Sign and remit Form - supporting documents must be attached 

                                             W2  Wages                            Ashtabula City Tax             Other City Tax
Employer/Work                               (Box 5 or 18)                          Withheld   (Box 19)           Withheld (Box 19) 
                                         Pro-Rate for Partial Year            Pro-Rate for Partial Year  Pro-Rate for Partial Year 
Location                                         Residents                           Residents                      Residents

          TOTALS
1. TAXABLE INCOME
   A.  Total - Wages, salaries, tips, etc.                                                                                             $
                                                                                                                                       $

   C. Gambling/Lottery Winnings (                                                                                                      $
   D.                             +                                                                                                    $
2. Ashtabula Income Tax 1.8% of Line 1D  or(1D X .018)                                                                                 $
3. CREDITS
       A. Ashtabula Income Tax withheld by Employer                                                      $ 
       B. Other Cities taxes withheld                                                                    $ 
       C. Es timated Tax Pai d                                                                           $
       D. Pr ior year Over payment Appl ied                                                              $
       E. Total Credits  (Add 3A thru 3D )                                                               $ 
4. TAX DUE (Line 2 - 3E)                                                                                                               $
5. PENALTY AND INTEREST
   A. Penalty (15%) of amount due by Jan 15, 2023         and not paid                            $ 
   B. Late Filing Fee - After April 1518 2023                                                     $
                                   Afte  r April 1815, 2023                                       $
   D. Total Penalty & Interest Due  (5A + 5B + 5C)                                                                                     $
6. OVERPAYMENT CLAIMED                                                                                                                 $
   A. Enter Amount of Line (6) Applied to 2023                                                    $ 
   B. En te Amount o Li ne (6)      unded                                                         $
7. Amount Due                                                                                                                          $ 

MANDATORY DECLARATION OF ESTIMATED TAX – Taxpayer’s owing more than $200.00 are required to declare and pay estimated tax 
8. Estimate of Taxable Income for 2023           (A) $                                X Ashtabula tax 1.8%                         (B)$
9. Estimate of Credits:     (A) Ashtabula Tax Withheld                        $
                              (B) Payments Applied (from Line  A)             $ 
                              (C) Total Line ( A +  B)                            $
                              (D) 2023                                                                                                 $
10. Quarterly Estimate Due  –Multiply Line 9D by .25                                                                                   $ 

                                                                                                                                       $ 
TOTAL AMOUNT DUE -                2022 $                     (Line 7)  +     2023  $               (Line 10)                                Payment in full is due with return 

____________________________________                     __________           _________________________________                    __________ 
Taxpayer’s Signature                                     Date                 Spouse’s Signature                                   Date
_______________________________________________________                       _________________________________________________________ 
Tax Preparer’s Name & Signature                                    Date       Tax Preparer’s contact information (phone/email) 
I, (we) authorize the City of Ashtabula Income Tax Dept to discuss my/our return and enclosures with the preparer above.  Initial here______________ 

                                  REFER TO INSTRUCTIONS BEFORE COMPLETING THIS PAGE
** Tax Returns will be considered incomplete if all applicable Federal Schedules and Forms are not included 

IMPORTANT CHANGES: Tax return must be signed, penalty is 15% of tax due, interest is .                                     % per month and a late
filing fee of $25.00 PER MONTH up to $150.00 is imposed, accurately calculated refunds or tax due of less than 
$10.01 is not payable, rental owners may carryforward losses to future years to offset rental income (see Ordinance),
due dates of individual estimates are 04/18      /23, 06/15/23                 , 09/15/23, and 1/15/24.  
******************************************************************************************************************************************************************** 
Assistance is available; please contact our office.  Online payments can be made at: www.cityofashtabula.com.
******************************************************************************************************************************************************************** 
                     Business Profit  Loss.  Enter amount from Federal Schedule C, 1120, or 1120S 
                     $__________________
                Enter Profit  Loss from Federal form 4797 
                     $__________________
             E  nter Profit  Loss from Federal Schedule E  (Attach Tenant List) 
            $__________________  
                                                                                                             
                     All Other Taxable Income: Schedule K-1  –Partnership Income, 1099-Misc, 
                      Schedule F, Estates & Trusts, Tips, Commissions, etc.                                   $__________________ 
            
            $___________________    

             Total of Lines 13 thru 16A.  Carry forward to page 1, Line 1B                                        $

                         INDIVIDUAL TAXPAYERS PLEASE STOP HERE 

                                                                                                             $__________________ 

ITEMS NOT DEDUCTIBLE                                                      ADD                   ITEMS NOT TAXABLE                DEDUCT 
18a) Capital Losses (Excluding Ordinary Losses)                     $ _______________    18f) Capital Gains                $
18b) Expenses incurred in the production of non-                                          (Excluding Ordinary Gains) 
       Taxable income                                               $_______________     18g) Interest Income              $
18c) Taxes based on income                                          $_______________     18h) Dividends                    $
18d) Other not deductible (Federally Deferred)                      $_______________     18i) Other                        $
18e) Total Lines 18 a thru 18 d                                     $_______________      18j) Total Lines 18f thru 18i)   $

                                                                                                             $__________________ 
                                                                                                              Carry forward to Page 1; Line 1B 

                                                                                      a. LOCATED    b. LOCATED IN          C. PERCENTAGE 
                                                                                         EVERYWHERE     ASHTABULA           (  / b a) 
STEP 1A - AVERAGE VALUE OF REAL & TANG. PERSONAL PROPERTY
STEP 1B - GROSS ANNUAL RENTALS PAID MULTIPLIED BY 8. 
TOTAL STEPS 1A & 1B                                                                                                                   % 
STEP 2 - GROSS RECEIPTS FROM SALES MADE AND/OR  
          SERVICE PERFORMED                                                                                                           % 
STEP 3 - WAGES, SALARIES, AND OTHER COMPENSATION PAID                                                                                 % 
STEP 4 - TOTAL PERCENTAGES  (Steps 1, 2, 3)                                                                                           % 
STEP 5 - PERCENTAGES (Divide Total Percentages by Number of Percentages Used)                                                         % 
STEP 6 -                                                                                                        

Disclaimer: All information stated on the tax return is correct at the time of printing and is subject to change in accordance with Ohio 
Revised Code. If your NOL usage schedule differs from the one above, please provide for our review. NOL calculation subject to 
change pending changes to ORC 718.