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Form IR File with ACCOUNT
CITY OF MIDDLETOWN
INCOME TAX DIVISION
P.O. Box 428739 FEDERAL EXTENSION REQUESTS MUST BE ATTACHED TO YOUR RETURN. (513) 425-7862
Middletown, Ohio 45042 EXTENSION REQUESTS MUST BE RECEIVED BEFORE APRIL 15,52016 www.cityofmiddletown.org
I AM NOT REPORTING ANY INCOME ON THIS RETURN BECAUSE:
___ ACTIVE DUTY MILITARY ___ ONLY INCOME IS FROM NON-TAXABLE SOURCE, LIST SOURCE __________________________________________
___ NO EMPLOYMENT THIS YEAR ___ MOVED FROM MIDDLETOWN ON _______________________ LIST DATE
___ UNDER 1618YEARS OF AGE, ___ TAXPAYER DECEASED, LIST DATE OF DEATH: _________________________________________________________
DATE OF BIRTH ___________________ ___ 65 YEARS OR OLDER, NON-TAXABLE INCOME ONLY. DATE OF BIRTH _____________________________________
IF NAME OR ADDRESSNAMEIS INCORRECT& PRESENTMAKEADDRESSNECESSARY CHANGES EMAIL: __________________________________________________________
(LIST BOTH(LIST BOTHNAMESNAMES& SOCIAL& SOCIALSECURITYSECURITYNUMBERS,NUMBERS IFONLYFILINGIFAFILINGJOINT RETURN)A JOINT RETURN) TAXPAYER SSN: _________________________________________________
SPOUSE SSN: __________________________________________________
PHONE - HOME: ___________________ BUSINESS: ___________________
IF YOU MOVED DURING THE YEAR YOU MUST COMPLETE LINES BELOW
DATE OF MOVE IN: __________________ OUT:____________________DATE OF MOVE: _________________________________________________
___________________________________________________________PRESENT ADDRESS: _____________________________________________
________________________________________________________________
OLD ADDRESS: __________________________________________________
________________________________________________________________
1. QUALIFYING WAGES, SALARIES, TIPS AND OTHER EMPLOYEE COMPENSATION (ATTACH ALL W-2 FORMS) . . . . . . . . . . . . . . . . . . . . . . . . 1.
(USUALLY BOX 5 OF W2)
2. INCOME OTHER THAN WAGES FROM WORKSHEETS ON REVERSE - LOSS 2a OR PROFIT . . . . . . . . . . . . . . . . . . 2b.
(ATTACH FEDERAL SCHEDULES AND/OR 1099 MISC)
3. TOTAL INCOME (ADD BOX 1 AND 2b) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.
4. MIDDLETOWN TAX - BOX 3 MULTIPLIED BY 1.75%2.0%. ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.
5. a. MIDDLETOWN TAX WITHHELD. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5a.
b. CREDIT FOR OTHER CITY TAX WITHHELD (not to exceed 1.75%)2.0%)WORKSHEET ON BACK . . . . . . . . . . . . . . . . . . . . 5b.
c. SUBTOTAL OF CREDITS - ADD 5a AND 5b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5c.
d. ESTIMATE PAYMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5d.
e. PRIOR YEAR CREDIT CARRIED FORWARD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5e.
f. TOTAL OF CREDITS - ADD 5c, 5d, AND 5e. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5f.
6. IF BOX 4 IS GREATER THAN BOX 5F ENTER BALANCE DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.
CHECK PAYABLE TO MIDDLETOWN INCOME TAX DIVISION NONOTAXTAXDUEDUEOROR REFUNDEDREFUNDED
(SEE REVERSE FOR CREDIT CARD PAYMENT) IFIF LESSLESSTHANTHAN$10.01$3.00
7. IF BOX 5f IS GREATER THAN BOX 4 ENTER OVERPAYMENT .............................. . . . . . . . . . . . . . . . . 7.
a. AMOUNT TO REFUND________________________ OR b. CREDIT TO NEXT YEAR ______________________
NOTICE: By law, all refunds and credits in excess of $10.00 are reported to IRS.
INCLUDE A COPY OF YOUR 1040, PAGE 1INCLUDE A COPY OF YOUR 1040, PAGE 1
DECLARATION OF ESTIMATED TAX FOR YEAR
8. TOTAL ESTIMATED INCOME $ ___________________________ MULTIPLY BY TAX RATE 2.0% = TOTAL ESTIMATED TAX . . . . . . 8.
9. ESTIMATED WITHHOLDINGS:
a. ESTIMATED TAX TO BE WITHHELD BY EMPLOYER(S) FOR CITY OF MIDDLETOWN . . . . . . . . . . . . . . . . . . . . . . . 9a.
b. ESTIMATED TAX, NOT OVER 1.75%,2.0%, WITHHELD FOR OR PAYABLE TO OTHER CITIES . . . . . . . . . . . . . . . . . . . . . . 9b.
10. ESTIMATED TAX NOT WITHHELD BY EMPLOYERS (LINE 8 MINUS LINES 9a, 9b) (IF LESS(IF LESSTHANTHAN$200, NO$200,ESTIMATENO ESTIMATEDUE) . .DUE). . . . . . . . . . . 10.
11. TAX OVERPAYMENT FROM PREVIOUS TAX YEAR: ENTER AMOUNT FROM LINE 7b. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.
12. TOTAL ESTIMATED TAX DUE AND PAYABLE TO MIDDLETOWN DURING 20 (LINE 10 MINUS LINE 11). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.
13. a. TOTAL DUE: TAX DUE FOR (BOX 6) $ _________________ b. PLUS 1/4 ESTIMATED TAX (BOX 12) $ _______________ . . . . 13.
The undersigned declares that this return (and accompanying schedules) is a true, correct and complete
return for the taxable period stated. If this return was prepared by a Tax Practitioner, may we contact your
practitioner directly with questions regarding the preparation of this return? Yes No
FAILURE TO PAY ESTIMATE BY JAN 15 $ _______________________
FAILURE TO PAY ESTIMATE BY JAN 31 $ ______________________
__________________________________________________________________________________ FAILURE TO FILE BY APRIL 18 $ _______________________
Taxpayer Signature Date FAILURE TO PAY TAX DUE BY APRIL 15 ______________________
FAILURE TO PAY TAX DUE BY APRIL 18
___________________________________________________________________________________ FAILURE TO FILE BY APRIL 15 INTEREST $_____________________________________________
Spouse’s signature (if filing jointly, BOTH must sign even if only one had income.) Date
TOTAL PENALTY & INTERESTPENALTY $_____________________________________________
___________________________________________________________________________________ TOTAL PENALTY & INTEREST $ _______________________
Tax Preparer (Print name and phone if other than taxpayer)
GRAND TOTAL $ _______________________
