Declaration of Estimated Taxes for the Tax Year __________

Your first name and initial        Last Name
                                                           Amherst Income Tax Department
Spouse's first name and initial    Last Name               480 Park Avenue
                                                           Amherst, OH  44001
Home address (number and street)               Apt. No.    phone (440) 988-4212       fax (440)-988-3749
                                                           email:  incometax@amherstohio.org

City, town or post office, state, and ZIP code             Your social security number Spouse's social security number

                                                        Computation of Estimated Taxes

1). Total estimated income subject to tax                                                   $

     Multiply line 1 by the city income tax rate (1.5%)                                     X           0.015

2). Total estimated tax                                                                     $

3). Estimated income tax to be withheld or paid to other cities                             $
(This amount would be 1% (.01) of line 1 if you are working in 
another city that has a tax rate equal to or greater than 1%. )

4).  Balance of city income tax declared.  Subtract line 3 from line 2                      $

5). Tax due.  Enter at least 25% of line 22                                                 $
Checks are made payable to "Amherst Income Tax Department" and mailed to the address above.  

Estimated Taxes in the City of Amherst are not mandatory. Please indicate with a check mark, 
the quarter that you are remitting. The schedule below shows due dates for each quarter. 
You will be billed accordingly.

                                               1st Quarter Due April 15th
                                               2nd Quarter Due June 15th
                                               3rd Quarter Due September 15th
                                               4th Quarter Due January 15th

Taxpayer's Signature______________________________Date___________Telephone Number (____)_____________
Spouse's Signature_______________________________Date___________Telephone Number (____)_____________
Preparer's Signature______________________________Date___________Telephone Number (____)_____________