Staple W-2(s) and the front page of the 1040 to the back of this page
City of Englewood, Income Tax Division
Form IR 1- City Income Tax Return For Individuals Tax Year ____
Acct # Check the appropriate box if:
Primary’s Social Security Number REFUND for(Anthisamountreturnmustto bebeconsideredplaced onaLinevalid8B
Primary’s First Name and Middle Initial Last Name refund request)
If Joint, Spouse’s First Name and Initial Last Name Spouse’s Social Security Number AMENDED For Tax Year _____________
Home Address (number and street) Resident Single
Non-Resident Married—Filing Jointly
Partial Year Complete PART E section 3 Married—Filing Separately
City State Zip Code
PART A TAX CALCULATION
Column A Column B Column C Column D Column E Column F Column G
Box 5 or 18 from the W2 PART E or Colume B Limited to 1.75%
List each Employer Separately (whichever amount is higher) Adjustments to Wages Tax (C) times 1.75% Englewood Other City (D) less (E) and (F)
EMPLOYER Wages (W2 Income) Taxable Wages Rate Tax Due Tax Withheld Tax Credit Balance Due
1.75%
1.75%
1.75%
1 TOTAL TAX DUE FROM W2 INCOME Total Wages Total Taxable Wages Total Tax Due WithheldTotal Englewood Total Other City Credit 1
2 TOTAL TAX DUE FROM OTHER INCOME (PART B Line 12) …………………………………………………………………………….… 2
3 GRAND TOTAL OF TAX DUE FROM ALL SOURCES OF INCOME (Total of Line 1 and 2) …………………………………………………………..…………… 3
4 LESS CREDITS FOR ESTIMATED TAX PAYMENTS AND OVERPAYMENT FROM PRIOR YEAR RETURN ONLY …………… 4
5 BALANCE DUE (Line 3 less Line 4) (If line 4 is greater than Line 3, enter amount here and carry to Line 8) ……………………………….………………….………….. 5
6 PENALTY $________________ INTEREST $_______________ LATE CHARGE $_______________ …..………………………………………………. 6
7 TOTAL AMOUNT DUE (add Lines 5 and 6) If amount due is $10 or less no payment is required …………………………………………………………………………………….. 7
8 OVERPAYMENT CLAIMED (if Line 4 exceeds Line 3) ………………………………………………………………………………...……… 8
A Enter the amount from Line 8 you want CREDITED to your next year tax estimate ……………………….. 8A
B Enter the amount from Line 8 you want REFUNDED (must be greater than $10.00) …………………………………………………………….. 8B
PART B OTHER INCOME Income from sources other than W2(s) See PART F or PART G or SCHEDULE Y for additional schedules
Column H Column I Column J Column K Column L
INCOME (OR LOSS) FROM RENTAL INCOME (OR LOSS) OTHER INCOME
DESCRIPTION PART F OR SCHEDULE Y PART G OTHER INCOME GAMBLING WINNINGS TOTAL
9 TOTAL OTHER INCOME (Total of Column L) ………………………………………………………………………………………………...………….. 9
10 TOTAL TAX DUE (Total of Column L times 1.75% tax rate) ……………………………………………………………………………………………...... 10
11 CREDIT FOR TAXES PAID TO OTHER CITIES (limited to 1.75% of taxed income per activity) ……………………….………………………………. 11
12 TOTAL TAX DUE ON OTHER INCOME (Line 10 less Line 11 ) (Place this amount on Line 2 above) …………………………………………………………... 12
PART C DECLARATION OF ESTIMATED CITY INCOME TAX - If you owe more than $200 on line 5 you must complete this section
13 TOTAL ESTIMATED INCOME FROM WAGES AND OTHER INCOME ………………..……………………………………………...………….. 13
14 TOTAL TAX DUE (Line 13 times 1.75% tax rate) (if under $200, there is no need to proceed) …………………………………………………...……...... 14
15 CREDIT FOR TAXES PAID TO OTHER CITIES or ENGLEWOOD or ON THE ACCOUNT (Limited to 1.75% of taxed income per activity) ………. 15
16 TOTAL AMOUNT OF DECLARATION FOR TAX YEAR (Line 14 less Line 15 ) …………….…………….…....…………………………………… 16
17 QUARTERLY PAYMENTS DUE (Line 16 divided by 4)…………………………………………………………………………………………………... 17
PART D SIGNATURES
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, and 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.
Sign Primary’s Date Email theByCitycheckingto communicatethis box I giveto mepermissionat this email.to
Here Signature
If a joint return Spouse’s Date Email theByCitycheckingto communicatethis box I giveto mepermissionat this email.to
both must sign Signature
Preparer’s Preparer’s Phone Number CONTACT INFORMATION
Use Only Signature 333 W National Rd
Englewood, OH 45322
Third Do you want to allow another person to discuss this matter with the City of Englewood? (see instructions) YES Complete the following NO 937-836-5106
Party Designee’s Name Phone Number tax@englewood.oh.us
Designee