FILE THIS FORM ON OR BEFORE THE DUE DATE OF THE RETURN WITH:                                                                   CITY OF WESTERVILLE, OHIO
APPLICATION FOR EXTENSION OF TIME TO FILE                                                                                      Division of Revenue
                                                                                                                               PO Box 130, 64 East Walnut Street
WESTERVILLE CITY INCOME TAX RETURN                                                                                             Westerville, OH 43086-0130
FOR CALENDAR YEAR ENDING DECEMBER 31,                                                                                          Tel # (614) 901-6420
                                                                                                                               Fax # (614) 901-6820
OR FISCAL PERIOD                          TO                                                                                   Website: www.westerville.org

NAME(S) 

ADDRESS 

CITY                                                                                                                     STATE ZIP

SOCIAL SECURITY NO. OF TAXPAYER(S) OR FID # 

PLEASE NOTE:         File this form with the City of Westerville on or before the due date of the return and pay any amount you owe.
                                          THIS IS NOT AN EXTENSION OF TIME TO PAY YOUR TAX.

I request an automatic six month extension of time to file the City of Westerville Income Tax for the tax year ending .................
Fiscal year filers enter extended due date.........................................................................................................................................
1. Total Westerville tax liability due 2.0% (.02)...............................................................................................................................   $ 
2. Total payments and credits........................................................................................................................................................ ( $ )
3. Balance due. Subtract Line 2 from Line 1. ................................................................................................................................      $ 
Complete the declaration of estimated taxes if liability to Westerville will exceed $100.00.
A. Estimated income subject to Westerville tax.........................................................................  $ 
   Estimated tax due: 2.0% (.02) times Line A. ......................................................................... $ 
B. WESTERVILLE tax to be withheld by employer .................................................................... ( $            )
C.  Credit allowed for income taxed by other cities (limited to 2%)........................................... ( $                )
D. DECLARATION OF ESTIMATED TAX DUE (Line A less Lines B and C)................................                          $ 
4. Amount of Declaration due. (Enter 25% of Line D if quarterly, 50% if semi-annually or 100% if annually) ............................                                            $ 
   Reminders for Quarters 2, 3 & 4 will be sent to you based upon the declaration and payments made.
5. Total amount due. Add Lines 3 and 4.....................................................................................................................................        $ 

                     IN ORDER TO RECEIVE AN EXTENSION,YOU MUST PAY IN FULL THE BALANCE DUE WITH THIS FORM

SIGNATURE AND VERIFICATION

Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the best of my knowledge 
and belief, it is true, correct and complete and, if prepared by someone other than the taxpayer, that I am authorized to prepare this form.

Signature of Taxpayer or Authorized Representative                                                                                                                                 Date 

Signature of Spouse                                                                                                                                                                Date 

INSTRUCTIONS

Use this form, copy of Federal Extension or letter to request an automatic six month extension from the due date of return. To receive the extension you must:

1. Complete form correctly, and
2. File it by DUE DATE of your return, and
3. Pay all of the amount shown on line 5.

We will contact you only if your request is denied.

This form does not extend the time to pay taxes. If you do not pay the amount due by the regular due date, you will owe interest and penalty. There is also 
a failure to file penalty that can be assessed. If you wish a return copy of the approved request, you must include a self-addressed stamped envelope.