CHECK ALL THAT APPLY: Individual       Proprietor   Partner/Partnership  Corporation  S Corp    LLC Amended Return            1  time filer st REFUND 

MAKE CHECK OR MONEY ORDER TO:                                                                       Primary SSN or
CITY OF ASHTABULA   TAX DEPT –                    INCOME TAX RETURN                                 Federal ID 
4717 MAIN AVE., STE. A                                           2023
ASHTABULA, OHIO 44004                                                                               Spouse SSN 
Phone: (440) 992-7104 Fax: (440) 992-7556
Email: incometax@cityofashtabula.com                DUE DATE APRIL 15,        2024                  Phone No. 
Name:                                                                                               Email Address:
Spouse Name:                                                                                        MOVE IN       OUT          DATE:
Address:                                                                                                      (Fill in circle)
                                                                                                    FORWARDING OR NEW ADDRESS: 
                                                                 FILE# 

RETIRED AND TAXPAYERS WITH NO TAXABLE INCOME:  REASON  (CHECK APPROPRIATE BOX TO INACTIVATE ACCOUNT) 
     ACTIVE DUTY MILITARY                         RETIRED WITH ONLY NON-TAXABLE INCOME       RETIREMENT DATE 
     TAXPAYER DECEASED                            ONLY INCOME FROM NON-TAXABLE SOURCE; LIST SOURCE 
STOP HERE: Sign and remit Form - supporting documents must be attached 

                                             W2  Wages                       Ashtabula City Tax          Other City Tax
Employer/Work                               (Box 5 or 18)                     Withheld   (Box 19)        Withheld (Box 19) 
                                       Pro-Rate for Partial Year         Pro-Rate for Partial Year  Pro-Rate for Partial Year 
Location                                     Residents                          Residents                      Residents

          TOTALS
1. TAXABLE INCOME
   A.  Total - Wages, salaries, tips, etc.                                                                                    $
                                                                                                                              $

   C. Gambling/Lottery Winnings (                                                                                             $
   D.                           +                                                                                             $
2. Ashtabula Income Tax 1.8% of Line 1D   (1D X .018)or                                                                       $
3. CREDITS
       A. Ashtabula Income Tax withheld by Employer                                                 $ 
       B. Other Cities taxes withheld                                                               $ 
       C. Es timated Tax Pai d                                                                      $
       D. Pr ior year Over payment Appl ied                                                         $
       E. Total Credits  (Add 3A thru 3D )                                                          $ 
4. TAX DUE (Line 2 - 3E)                                                                                                      $
5. PENALTY AND INTEREST
   A. Penalty (15%) of amount due by Jan 15, 2024       and not paid                         $ 
                                                                                             $
                                             15   2024                                       $
   D. Total Penalty & Interest Due  (5A + 5B + 5C)                                                                            $
6. OVERPAYMENT CLAIMED                                                                                                        $
   A. Enter Amount of Line (6) Applied to 2024                                               $ 
   B. En te Amount o Li ne (6)    unded                                                      $
7. Amount Due                                                                                                                 $ 

MANDATORY DECLARATION OF ESTIMATED TAX – Taxpayer’s owing more than $200.00 are required to declare and pay estimated tax 
8. Estimate of Taxable Income for 2024       (A) $                               X Ashtabula tax 1.8%                         (B)$
9. Estimate of Credits:     (A) Ashtabula Tax Withheld                    $
                              (B) Payments Applied (from Line  A)         $ 
                              (C) Total Line ( A +  B)                       $
                              (D) 2024                                                                                        $
10. Quarterly Estimate Due   Multiply Line 9D by .25–                                                                         $ 

                                                                                                                              $ 
TOTAL AMOUNT DUE -                2023 $                   (Line 7)  +  2024  $               (Line 10)                           Payment in full is due with return 

____________________________________                __________            _________________________________                   __________ 
Taxpayer’s Signature                                Date                  Spouse’s Signature                                  Date
_______________________________________________________                   _________________________________________________________ 
Tax Preparer’s Name & Signature                                  Date     Tax Preparer’s contact information (phone/email) 
I, (we) authorize the City of Ashtabula Income Tax Dept to discuss my/our return and enclosures with the preparer above.  Initial here______________ 

                     REFER TO INSTRUCTIONS BEFORE COMPLETING THIS PAGE
** Tax Returns will be considered incomplete if all applicable Federal Schedules and Forms are not included 

IMPORTANT CHANGES: Tax return must be signed, penalty is 15% of tax due, interest is .                          % per month and a

                                  15             24,  24        ,       24,              25.  
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Assistance is available; please contact our office.  Online payments can be made at: www.cityofashtabula.com.
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            Business Profit  Loss.  Enter amount from Federal Schedule C, 1120, or 1120S 
            $__________________
                Enter Profit  Loss from Federal form 4797 
            $__________________
             E  nter Profit  Loss from Federal Schedule E  (Attach Tenant List) 
            $__________________   
                                                                                                  
            All Other Taxable Income: Schedule K-1   Partnership Income, 1099-Misc, –
             Schedule F, Estates & Trusts, Tips, Commissions, etc.                                 $__________________ 

            $___________________     

             Total of Lines 13 thru 16A.  Carry forward to page 1, Line 1B                           $

            INDIVIDUAL TAXPAYERS PLEASE STOP HERE 

                                                                                                  $__________________ 

ITEMS NOT DEDUCTIBLE                                       ADD                 ITEMS NOT TAXABLE                      DEDUCT 
18a) Capital Losses (Excluding Ordinary Losses)  $ _______________            18f) Capital Gains                $
18b) Expenses incurred in the production of non-                               (Excluding Ordinary Gains) 
       Taxable income                            $_______________             18g) Interest Income              $
18c) Taxes based on income                       $_______________             18h) Dividends                    $
18d) Other not deductible (Federally Deferred)   $_______________             18i) Other                        $
18e) Total Lines 18 a thru 18 d                  $_______________              18j) Total Lines 18f thru 18i)   $

                                                                                                  $__________________ 
                                                                                                   Carry forward to Page 1; Line 1B 

                                                                   a.   LOCATED          b. LOCATED IN          C. PERCENTAGE 
                                                                        EVERYWHERE           ASHTABULA           (  / b a) 
STEP 1A - AVERAGE VALUE OF REAL & TANG. PERSONAL PROPERTY
STEP 1B - GROSS ANNUAL RENTALS PAID MULTIPLIED BY 8. 
TOTAL STEPS 1A & 1B                                                                                                        % 
STEP 2 - GROSS RECEIPTS FROM SALES MADE AND/OR  
          SERVICE PERFORMED                                                                                                % 
STEP 3 - WAGES, SALARIES, AND OTHER COMPENSATION PAID                                                                      % 
STEP 4 - TOTAL PERCENTAGES  (Steps 1, 2, 3)                                                                                % 
STEP 5 - PERCENTAGES (Divide Total Percentages by Number of Percentages Used)                                              % 
STEP 6 -                                                                                             

Disclaimer: All information stated on the tax return is correct at the time of printing and is subject to change in accordance with Ohio 
Revised Code. If your NOL usage schedule differs from the one above, please provide for our review. NOL calculation subject to 
change pending changes to ORC 718.

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