City of Lakewood - Division of Municipal Income Tax 
                                                             12805 Detroit Ave., Suite 1 
                                                                         Lakewood, OH  44107 
                                       Telephone:   (216) 529-6620  Fax:  (216) 529-6099 
                                                                 www.lakewoodoh.gov     
                                                                                    
                       Form L-ES – Declaration of Estimated Tax for Individuals 
                                                                                   
                                                             Tax Year: ___________ 
                                                                                   
Per Lakewood Ordinance §128.1303 and 128.1304, taxpayers owing two hundred dollars ($200.00) or more of estimated 
tax are required to file a declared estimate of income tax on or before the April filing deadline, or within four (4) months 
of the date the taxpayer becomes subject to tax for the first time. 
 
                       _________                                                                                    _________ 
Primary Social Security Number                                                         Spouse Social Security Number                    

_________________________________________        _____________________________________________ 
Primary Last Name                             First Name                        Initial            Spouse Last Name                            First Name                        Initial 

__________________________________________     _________________         _   ____       ______________ 
Present Address                                                   Apt. #              City                                      State              Zip Code 
 
ESTIMATED TAX CALCULATION 
 
1.  a. Total taxable income for current tax year                                          $____________ 
 
       Prorated Income (use this calculation if lived in Lakewood part of the year) 
       b. Annual income Line 1a / 12 months = $______________ 
       c. Monthly income Line 1b x _______ months in Lakewood = $____________ 
       Enter the applicable amount on Line 1 from Line 1a or Line 1c                                                       1. ___________________ 
                                                                                                                              (Line 1a or Line 1c) 
 
2.  Does your employer withhold income tax for the city you work in                                                        2. ___________________ 
       YES – enter 1% or .01 on Line 2 
       NO – enter 1.5% or .015 on Line 2 
 
3.  Multiply Line 1 by Line 2. Enter amount on Line 3. This is your estimated income                                       3. ___________________ 
       tax for the entire year. If this amount is less than $200 – STOP, no estimate required. 
 
4.  Multiply Line 3 by 25% or 0.25.                                                                                        4. ___________________ 
 
5.  Estimated income tax payments are BILLED quarterly on the following dates:                                             5. ___________________ 
       March 1st       May 15th                          August 15th          December 15 th
       Due April 15 th Due June 15  th                   Due September 15  th Due January 15 th

       Circle the dates that already passed as of the date you are completing this form and 
       enter the number of the dates circled above on Line 5. 
 
6.  Multiply Line 4 by Line 5. Enter the amount on Line 6. This is the amount due with                                     6. ____________________ 
       this form. 
 
I hereby declare the information supplied above to be true, correct and complete. 
 
Primary Signature _________________________________________________                                                 Date _________________________ 
 
Spouse Signature __________________________________________________                                                 Date _________________________ 
 
                       Mail completed form to the above Lakewood address or fax to: (216) 529-6099 

              INSTRUCTIONS FOR FORM DECLARATION OF ESTIMATED TAX 
                                                           
Per Lakewood Ordinance §128.1303 and 128.1304, taxpayers owing two hundred dollars ($200.00) or more of 
estimated tax are required to file a declared estimate of income tax on or before the April filing deadline, or  
within four (4) months of the date the taxpayer becomes subject to tax for the first time. 
 
 1. a. Enter the amount of total taxable income for the year. This includes income from wages, business 
    income, distributive income from businesses, rental property, gambling winnings etc. 
 
    UTILIZE THE FOLLOWING LINES ONLY IF YOU MOVED INTO LAKEWOOD DURING THE YEAR 
    b. Calculate your monthly income. Divide Line 1a by 12 months. 
    c. Calculate your total income for the time living in Lakewood. Multiply Line 1b by the months living in 
    Lakewood.  
 
    Enter the applicable amount on Line 1 from Line 1a or Line 1c. 
 
 2. Enter the applicable percentage or decimal on Line 2. 
     
 3. Multiply Line 1 by Line 2. Enter the amount on Line 3. This is your estimated income tax for the entire 
    year. If this amount is less than $200,   STOP, as no estimate tax declaration is required per Lakewood 
    Ordinance §128.1303. 
     
 4. Multiply Line 3 by 25% or .25. Enter the amount on Line 4. 
     
 5. Estimated income tax is billed by the City on a quarterly basis once a declaration of estimated tax has 
    been filed with our office. To ensure your declared estimate is entered the billing cycle at the appropriate 
    time, circle the dates that have already passed as of the date you are completing this form. Enter the 
    number of dates circled on Line 5. 
     
 6. Multiply Line 4 by Line 5. Enter the amount on Line 6. This amount is due with this form. If the amount 
    is zero, there is no payment due at this time, and your declared estimate will be entered into the billing 
    cycle upon submitting this form to our office. 
 
In all cases where the taxpayer is required to file an estimated tax declaration, the taxpayer must provide his/her 
social security number, name, and address.  
 
This declaration form is not valid and will not be processed without the taxpayer’s signature and date.