This form may be electronically filed and paid at www.columbus.gov/IncomeTaxDivision

                  City of Columbus, Income Tax Division
Form                                                                           For Calendar Year ending December 31,
IR-42 Application for Filing Extension                                                                                                                                           2021

Part A         ACCOUNT INFORMATION
                                                                    Primary Social Security Number
Name(s)                                                                                                       CITY OR CITIES OF INCOME
                                                                                                  -I          1. 
                                                                    Spouse’s Social Security Number (if joint)
Address
                                                                                                              2. 

City                                                                                                          3. 
                                                                    Filing Status - check only one
                                                                    Single                                    CITY OF RESIDENCE
State                             Zip Code                          Married-Filing Joint
                                                                    Married-Filing Separately                 1.

Part B         EXTENSION INFORMATION
     CITY         C  Column 1                          Column 2                Column 3                                                                                          Column 4
                  O 
                  D  ESTIMATED      TAX                                        LESS AMOUNT PAID ON                                                                               NET TAX DUE 
                  E         TOTAL   RATE               ESTIMATED    CURRENT ESTIMATE AND/OR                      TENTATIVE AMOUNT
                     TAXABLE INCOME                    TAX DUE      ANY OVERPAYMENT CREDITS

     COLUMBUS     01                2.5%

                                                                                  Payment
                                                                               (with this extension)            $

                                                                                                                Payment can only be accepted 
                                                                                                                for the city of Columbus.
Make payable to:  COLUMBUS CITY TREASURER 
Mail to:          Columbus Income Tax Division 
                  PO Box 182158 
                  Columbus, Ohio 43218-2158

If an extension of time is necessary, file this form on or before the due date with the Columbus Income Tax Division in accordance 
with the instructions available on our website www.columbus.gov/IncomeTaxDivision 
An extension of 180 days for filing a city income tax return for the year stated above is hereby requested for the following reason: 

This form only serves to extend the time to file a city tax return. Any tax remaining due after the original due date of the return will be 
subject to penalty and interest as prescribed in the city tax codes.

Part C         SIGNATURE

Signature of taxpayer(s).   I declare that the extension requested herein for filing a city income tax return for the taxable year 
                            stated is necessary for the reason given above and that I am authorized to sign this request.

         Signature                                                                                                        Date                                   Telephone Number
Sign 
Here

         Spouse’s Signature                                                               Date
                                                                                        Print Form                                                                               Reset Form

Rev.  12/1/2021