FORM R file with: CITY OF BROOKVILLE
Income Tax Office
P.O. Box 727 2022 INCOME TAX RETURN CHECK ONE:
333 J.E. Bohanan Memorial Dr. Resident
Vandalia, OH 45377 FILING REQUIRED EVEN IF NO TAX DUE Non-Resident
Phone: (937) 415-2240; Fax: (937) 415-2361 DUE ON OR BEFORE APRIL 18, 2023 Part Year Resident
Toll free: (866) 898-5891
Email: tax@vandaliaohio.org
www.vandaliaohio.org SOC. SEC. NO. ____________________________ FILING STATUS:
LIST NAME(S) AND ADDRESS BELOW. SOC. SEC. NO. ____________________________ Single
Taxpayer’s Occupation ______________________ Married
Spouse’s Occupation ________________________ Married, Filing Separate
Complete if moved since last return or part year resident:
Old Address ______________________________________________________
Date Moved (in) _________________________ (out) _____________________
Dates of Employment _______________________________________________
Did you file a city income tax return the previous year? YES NO
Email address _____________________________________________________
SECTION A RETIRED AND/OR TAXPAYERS WITH NO TAXABLE INCOME. PLEASE CHECK APPROPRIATE BOX BELOW:
Under 18 years of age for entire year. Date of Birth: _________________ (attach verification -copy of driver s’license or birth certificate) Active duty military for entire year.
All income was from a federally qualified retirement plan. Date retired: ______________ All income was from a non-taxable source. List source: ___________________________________
SECTION B Enter wages, salaries, bonuses, incentive payments, commissions, gambling winnings and other compensation, received between January 1 and December 31.
List each employer or source separately. Please attach all W-2 and W-2G forms.
City or Township Resident City Other City Tax Withheld
Employer Where Employed Tax Withheld (See Instructions) Taxable Wages
$ $ $
1. TOTAL WAGES & WITHHOLDING …………………………………………………………………... 1 A.- 1 B.- 1 C.-
2. TAXABLE INCOME Line 1-C (or Column 3 if applicable) ……………………………………………………………………………………………………………….. 2.
3. TAX DUE (2% x Line 2) ……………………………………………………………………………………………………………………................................................. 3.
4. TAX CREDITS
4-A. Resident City Tax Withheld (Line 1-A) ……………………………………………………………………………………………. 4- A.
4-B. Other City Tax Credit (Not to exceed 2%) (Line 1-B) ……………………………………………………………………………. 4- B.
4-C. Other: Estimates, Direct Payments, Credit from Prior Year ……………………………………………………………………….. 4- C.
4-D. Total Credits Available (Line 4-A + 4 B- + 4 C) - …………………………………………………………………………………………………………………….. 4- D.
5. BALANCE OF TAX DUE (Line 3 -Line 4-D) ……………………………………………………………………………………………………………………………... 5.
6. PENALTY $ ________________________ INTEREST $ ________________________ LATE FEE $ ________________________ ………………………….. 6.
7. TOTAL AMOUNT DUE (Make check payable to City of Vandalia) (No payment due if $10.00 or less) ………………………………………………………………. 7.
8. IF OVERPAYMENT, CREDIT TO NEXT YEAR ($10.01 minimum): $____________________ or REFUND $____________________
Reviewed by ____________________ Check No. ____________________ Cash ____________________ Amt. Received ____________________
SECTION C -DECLARATION OF ESTIMATED TAX FOR 2023
9. Total Income Subject to Tax $_______________ X Tax Rate (2%) ……………………………………………………………………………………………………………… 9.
10. Subtract Credit for Tax Withheld (Other city credit not to exceed 2%) ………………………………………………………………………………………………………….. 10.
11. Net Tax Due (Line 9 -Line 10) See General Information, Section 13 …………………………………………………………………………………………………………... 11.
12. Quarterly Amount Due (1/4 of Line 11) ………………………………………………………………………………………………………………………………………….. 12.
13. Credit from Line 8 ($10.01 minimum) ……………………………………………………………………………………………………………………………………………. 13.
14. Amount of Estimated Tax Due (Line 12 -Line 13) ………………………………………………………………………………………………………………………………. 14.
15. Total of this Payment (Line 7 + Line 14) …………………………………………………………………………………………………………………………………………. 15.
SECTION D Please refer to the website, www.vandaliaohio.org, to access the online payment center to pay by credit card or electronic check.
Credit card payments are now accepted in person in the tax office as well.
The undersigned declares that this return (and accompanying schedules) is a true, correct and complete return for the taxable period stated and that the figures used herein are the same as used for federal income tax
purposes, adjusted to the ordinance requirements for local tax purposes. If an audit of the federal return is made which affects the tax liability shown on the return, an amended return is required to be filed within three
months. 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
Signature of Person Preparing Return (If Other Than Taxpayer) Date Signature of Taxpayer Date
Phone Number Signature of Spouse Date