OFFICE USE ONLY 
 Acct # ____________________ 
                                        CITY OF WAUSEON   
 Payment $_________________ 
 Check # ___________________                      INDIVIDUAL INCOME TAX RETURN 
                                                  DUE ON OR BEFORE APRIL 15 OR IRS DUE DATE 
 Cash  □- Credit Card    -□ACH      □
    Refund  □    Carryover  □                                  TAX YEAR _________ 
                                                                                                                       
MAIL TO:  Wauseon Income Tax Department                                     PHONE: 419-335-1171 
                    230 Clinton St.                                         FAX: 419-335-0063 
                    Wauseon, OH 43567                                       WEBSITE: www.cityofwauseon.com 
 
NAME(S): _______________________________________________                     TAXPAYER SS #: _______________________________  

ADDRESS: _______________________________________________          SPOUSE SS#: _________________________________ 
                   _______________________________________________          DATED MOVED IN: ___________OUT: ____________ 
PHONE: ________________________________________________                       MARITAL STATUS CHANGE: ⃝  ADDRESS CHANGE:  ⃝ 
EMAIL: _________________________________________________              FINAL RETURN:  ⃝ EXPLAIN: ____________________ 
 
1.  COMPENSATION FROM WAGES – WORKSHEET A TOTAL BOX A………………………………….………………...1. $____________________ 
          *Attach all W-2’s, Federal 1040 pg.1, Schedule 1 and any other relevant forms. 

2.  OTHER INCOME/LOSS – WORKSHEET B LINE 6……………….……………………………………..……………….…….. 2. $____________________ 
          *Losses cannot be deducted from W-2 income. 

3.  TOTAL INCOME SUBJECT TO WAUSEON INCOME TAX (add lines 1 & 2) …………………………………….…. 3. $____________________ 

4.  WAUSEON INCOME TAX @ 1 ½% (.015) OF AMOUNT ON LINE 3……………………………………………….…. 4. $____________________ 

5. CREDITS 
     a. WAUSEON INCOME TAX WITHHELD – WORKSHEET A BOX B………………….…. a. $___________ 
     b. OTHER CITY INCOME TAX WITHHELD (1% limit) WORKSHEET A BOX C……... b. $___________ 
       *If any portion of the credit is refunded by the other city the credit is not allowed. If refund of tax withheld is discovered after filing of return, the return will be 
       corrected and you are responsible for any balance due. 
     c.  ESTIMATED TAX PAID/PRIOR YEAR OVERPAYMENT………………………………...… c. $____________ 
     d.  TAXES PAID TO OTHER CITIES – 1% Limit (Attach return) ............................ d. $____________ 
     e. TOTAL CREDITS – (add lines 5a thru 5d) ………………………………………………………………………………….…. 5. $___________________ 

6. BALANCE OF TAX DUE      (line 4 minus line 5) Amounts under $10 are not due, credited, or refundable.…....… 6. $___________________ 

7. OVERPAYMENT – If tax credits exceed tax due, enter difference……………………………………………………….…. 7. $___________________ 
                 a. Refund  $_______________                  b. Carryover  $___________________ 

8. PENALTY/INTEREST 
     a. UNDERPAYMENT/LATE PENALTY (see instructions) – Multiply line 6 X 15% (.15) …. a. $___________ 
     b. INTEREST OF LINE 6 (See website for %) REGARDLESS OF EXTENSION…………………… b. $___________ 
     c. LATE FILING FEE $25……………………………………….……………………………………………… c. $___________ 
     d. TOTAL PENALTIES & INTEREST (Add lines 8a thru 8c) ……….……………………………………………………….……. 8. $___________________ 

9. TOTAL TAX, PENALTIES & INTEREST DUE (Line 6 plus Line 8) ……………………………………………….………….… 9. $___________________ 
     Make checks payable to the Commissioner of Taxation or City of Wauseon 
 
TAX PREPARER__________________________________________                TAXPAYER___________________________________________ 
Print Name ____________________________________________               TAXPAYER___________________________________________ 
Address _______________________________________________                    DATE __________________________ 
               _______________________________________________        ⃝ Check to authorize us to speak with preparer. 
Phone ______________________________________________________ 
                  

WORKSHEET A – W-2 INCOME (INCLUDE W-2G) 
                                                                                                                        WAGES EARNED               WAUSEON    Other City tax 
                                                                                                                     Greater of Box 5 or Box 18    Income Tax  withheld 
                   EMPLOYER                                             LOCATION                                         of W-2                    Withheld    (1% limitation) 
                                                                                                                                                               
      NUMBER OF W-2’S________ ATTACHED             TOTALS                                                            A.                         B.            C. 
    *Attach all W-2’s, Federal 1040 pg.1, & Schedule 1 
        
WORKSHEET B - BUSINESS INCOME OR LOSS  
                                                                                 Column A                                 Column B                     WAUSEON TAXABLE INCOME 
                                                                          Income or loss from                             Percent allocated         (COLUMN A x COLUMN  B 
   SCHEDULES                                                               Federal Schedules                              to Wauseon                FOR LINE 1 THROUGH 4) 
   1. SCHEDULE C - BUSINESS INCOME (Residents combine the net                                                                                       
        profit and loss of all Schedule C’s. Nonresidents a separate                                                                            % 
        allocation percentage is required for each Schedule C) 
   2. SCHEDULE E - RENTAL INCOME (Residents enter profit/loss from                                                                                  
        all properties. Nonresidents enter only profit/loss from 
        Wauseon properties)                                                                                                     100.00% 
   3. SCHEDULE K-1 - PARTNERSHIP INCOME                                                                                                             
        (Residents enter profit/loss from entities that do not withhold 
        Wauseon tax on entire distributive share)                                                                               100.00% 
   4. MISCELLANEOUS INCOME - 1099-MISC.,                                                                                                            
        SCHEDULE F, ETC.                                                                                                        100.00% 
   5. NET OPERATING LOSS CLAIMED TO OFFSET CURRENT YEAR BUSINESS INCOME                                                                             
        (Enclose a worksheet showing prior year losses for up to 5 years and amounts previously claimed.) (Enter the 
        amount claimed as a (deduction) *See instructions for limitations 
   6. TOTAL INCOME (LOSS) (Combine Lines 1 through 5 and                                                                                            
        enter this amount on Page 1, Line 2) 
    * Enclose copies of all Federal Forms and Schedules used to compute your local income .
    *  If taxes were paid to other cities, all returns must be included.   
  
    WORSHEET C – BUSINESS APPORTIONMENT FORMULA                                                                          
                                                                                                                     A. Located everywhere     B. Located in Wauseon     C. Percentage (B ÷ A) 
      STEP 1.     Average original cost of real & tangible person property         _________________     ________________       _______________ 
                          Gross annual rentals multiplied by 8                                                     _________________     ________________       _______________ 
                          TOTAL Step 1                                                                                             _________________     ________________       _______________ 
     STEP 2.        Wages, Salaries, and all compensation paid                                        _________________     ________________       _______________ 
     STEP 3.        Gross Receipts from sales made or work/services performed         _________________     ________________       _______________ 
     STEP 4.        Total percentages (add steps 1-3)                                                                                                                                              _______________ 
     STEP 5.        Apportionment Percentage (divide total percentage by number of percentages used)                                                  _______________ 
 
ESTIMATED PAYMENTS ARE REQUIRED 
Any taxpayer having or anticipating a tax liability to the City of Wauseon shall file a declaration of estimated tax and pay 
the estimated tax due in quarterly installments.  Complete the estimated Wauseon tax form (available on the website) for 
each quarterly payment and submit to the address provided. 

 *If a taxpayer’s income is from wages and the taxpayer’s employer withholds the proper amount of Wauseon tax, the taxpayer is not required to file 
an estimate of Wauseon tax due.