Form W-1                          CITY OF BLUE ASH                                  CITY OF BLUE ASH
Income Tax Dept.      EMPLOYER’S RETURN OF TAXES WITHHELD                           INCOME TAX OFFICE
(513) 745-8516                    blueashtax@blueash.com                            4343 COOPER ROAD
                                                                                    BLUE ASH, OH 45242-5699
                      This form must be submitted each period even if no tax is due.

                 1.25% tax withheld from employees' wages = $           for period checked.

                                                              o
FID#                  ACCT #                                   Jan. thru March,     20___ Due   4/30
                                                              o
                                                               April thru June,     20___ Due   7/31
                                                              o
NAME AND ADDRESS                                               July thru Sept.,     20___ Due 10/31
                                                              o
                                                               Oct. thru Dec.,      20___ Due   1/31
                                                              o
                                                               Month of
                                                                                    Due the 15th of the next month

PHONE NUMBER                 DATE                              SIGNATURE

Form W-1                          CITY OF BLUE ASH                                  CITY OF BLUE ASH
Income Tax Dept.      EMPLOYER’S RETURN OF TAXES WITHHELD                           INCOME TAX OFFICE
(513) 745-8516                    blueashtax@blueash.com                            4343 COOPER ROAD
                                                                                    BLUE ASH, OH 45242-5699
                      This form must be submitted each period even if no tax is due.

                 1.25% tax withheld from employees' wages = $           for period checked.

                                                              o
FID#                  ACCT #                                   Jan. thru March,     20___ Due   4/30
                                                              o
                                                               April thru June,     20___ Due   7/31
                                                              o
NAME AND ADDRESS                                               July thru Sept.,     20___ Due 10/31
                                                              o
                                                               Oct. thru Dec.,      20___ Due   1/31
                                                              o
                                                               Month of
                                                                                    Due the 15th of the next month

PHONE NUMBER                 DATE                              SIGNATURE

Form W-1                          CITY OF BLUE ASH                                  CITY OF BLUE ASH
Income Tax Dept.      EMPLOYER’S RETURN OF TAXES WITHHELD                           INCOME TAX OFFICE
(513) 745-8516                    blueashtax@blueash.com                            4343 COOPER ROAD
                                                                                    BLUE ASH, OH 45242-5699
                      This form must be submitted each period even if no tax is due.

                 1.25% tax withheld from employees' wages = $           for period checked.

                                                              o
FID#                  ACCT #                                   Jan. thru March,     20___ Due   4/30
                                                              o
                                                               April thru June,     20___ Due   7/31
                                                              o
NAME AND ADDRESS                                               July thru Sept.,     20___ Due 10/31
                                                              o
                                                               Oct. thru Dec.,      20___ Due   1/31
                                                              o
                                                               Month of
                                                                                    Due the 15th of the next month

PHONE NUMBER                 DATE                              SIGNATURE

01-2017