FORM 01  INCOME TAX                    
 P.O. BOX 230                          DECLARATION OF ESTIMATED WARREN, OHIO, CITY INCOME TAX 
 WARREN, OHIO 44482                     
                                       FOR THE PERIOD FROM JANUARY 1,__________THROUGH DECEMBER 31. ___________ _____ 
                                        
                                       OR FISCAL PERIOD BEGINNING ____________________________THROUGH _____________________________ 
 
               • ALL TAXPAYERS WHO ANTICIPATE TAXABLE                   INCOME OF $200.00 MUST FILE AN ESTIMATE        • 

                                        INDIVIDUAL DUE                DATES:                  NON-INDIVIDUAL DUE DATES: 
                                                        APRIL      15                                   APRIL 15  
                                                         JUNE 15                                        JUNE15 
                                            SEPTEMBER 15                                              SEPTEMBER   15 
                                                             JANUARY 15                                DECEMBER  15 
 
                                                                                SOCIAL SECURITY# (H) 
  
                                                                                           I  I   
                                                                                SOCIAL SECURITY I (W) 
 
                                                                                           I    I 
                                                                                FED.  D.#I.
                                                                                                         <Ill    PLEASE  PRINT  NAME,  ADDRESS, AND 
                                                                                      I                          SOCIAL  SECURITY  OR FEDERAL   I.D.# 
  
  1.TotalEstimated  Income Subject to Warren, CityOhio,Income  Tax..................................................              
  2. ESTIMATED WARREN, OHIO, CITY INCOME TAX (2.5%)                                                                               
  3. Less: ESTIMATED WARREN, OHIO, CITY INCOME  TAX to be withheld during year  ......................................            
  4.  BALANCE OF WARREN, OHIO, CITY INCOME TAX DECLARED                                                                           
  5. LESS CREDITS: a. Overpayment claimed on previous year's return                                                               
  b. Previous payments, if this is an amended estimate  .......................................       I                           
  6.  UNPAID BALANCE of net tax  due   ....................................,................ ······················· 
                                                                                                                                  
   ATTACH CHECK OR M.D. FOR AMOUNT DUE WITH THIS DECLARATION (22'/,% PMT DUE BY 4/15)                ...................... 
                                                                                                                                  
         SOCIAL SECURITYNUMBER:                         I.D.NUMBER:     I CERTIFY THAT THIS IS A CORRECT DECLARATION, SUBJECT TO AMENDMENT IN THE ORDINANCEAS PROVIDED 
 
                                                                        SIGNATURE OF TAXPAYER                                    DATE