Amended Return
City of Englewood, Income Tax Division Tax Year 20 __ __
Form IR-1 City Income Tax Return For Individuals
Primary’s First Name and Middle Initial Last Name Primary’s Social Security Number
Joint, Spouse’s First Name and Middle Initial Last Name Spouse’s Social Security Number
Home Address (number and street) Account Number - R DATE RECEIVED
City State Zip Code Filing Status: TAX OFFICE USE ONLY:
Englewood Residency Status: Full-Year Part-Year Non-Resident Single PAYMENT AMOUNT __________________
Married—Filing Jointly
If part-year, give residency dates: Moved in __________________ Moved out _____________________ Married—Filing Separately CASH/CHECK/CC# ____________________
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 Column 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 Total Englewood Withheld 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) FROM 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 3 you must complete this section
Staple W-2(s) and the front page of the 1040 to the back of this page
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 ) (The final day to pay this amount is January 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 By checking this box I give permission to the
Signature City to communicate to me at this email.
If a joint return Spouse’s
Here Date Email By checking this box I give permission to the
Signature City to communicate to me at this email.
Preparer’s Preparer’s Phone Number CONTACT INFORMATION
Use Only Signature City of Englewood
Income Tax Department
333 W National Rd
Do you want to allow another person to discuss this matter with the City of Englewood? (see instructions) YES Complete the following NO Englewood, OH 45322
Third Designee’s Name Phone Number 937-836-5106
tax@englewood.oh.us