City of Englewood, Income Tax Division 
                                                                                                                  Tax Year 20 2 __ 
     Form BR 1-  City Income Tax Return For Business                                                                          OR 
                                                                                                              Fiscal Year 20 2 __ 
                                                                                                             
   Business   Name                                                                                        B eginning  _____ /_____ /_____ 
                                                                                                           Ending       _____ /_____ /_____                                           
                                                                                                                                                   
  Address 
                                                                                                              Amended Return                        Final Return 
                                                                                                                              Filing Status:                                           
   Address                                                                                                                                                                                                            DATE RECEIVED 
                                                                                                              C Corporation-                                                           TAX OFFICE USE ONLY: 
                                                                                                              S- Corporation                                                            
   City                                                 State                Zip Code                         Partnership                                                              PAYMENT AMOUNT __________________    
                                                                                                              LLC                                                                       
                                                                                                              Fiduciary (Trusts/Estates)                                               CASH/CHECK/CC# ____________________ 
                                                                                                     - B 
  Federal ID#                                                                Account Number 
  SECTION        A    
        1. INCOME PER ATTACHED FEDERAL RETURN                    ………………………………………..…………………. …………………………..                                                                                                     1 
        2.      ITEMS NOT DEDUCTIBLE (From Line M, Schedule X reverse page)         …………………………………….                                                                                        2                 
        3.      ITEMS NOT TAXABLE (From Line Z, Schedule X reverse page)     ………………………………………….                                                                                             3                 
        4. TAXABLE INCOME  (Line 1 + Line 2   Line- 3)           …..……………………………………………………………………………………...                                                                                                     4 
       5. NET OPERATING LOSS FROM 2017 OR AFTER                   ……………………………………………………………..                                                                                                                 5 
          6. TAXABLE INCOME AFTER NET OPERATING LOSS DEDUCTION               ……………………………………………...………………….                                                                                                   6 
        7. AMOUNT OF THE APPORTIONMENT FOR THE CITY OF ENGLEWOOD  (Schedule Y _________% x Line 4)                                             ……...................                                        7 
          8. TAX DUE  (Line 5 x 1.75%)    ………………………………………………………………………………………………………………..                                                                                                                      8 
          9. TAX CREDITS                                                                                                                                                                                     
                   9A  Estimated Tax Paid ……………………………………………………………………………………….                                                                                                               9A                
                   9B  Credit from Prior Year ……………………………………………………………………………………..                                                                                                           9B                
                   9C  Total Credits Available (Line 9A + Line 9B) …………………………………………………………………………...………...                                                                                                    9C 
      10. BALANCE OF TAX DUE (Line 8   Line- 9C)             …………………………………………………………………………………………….                                                                                                           10 
      11. PENALTY $__________ INTEREST $________ LATE FEE $_________                …………………………………………………………                                                                                                  11 
      12.     TOTAL AMOUNT DUE (Make Check Payable to the City of Englewood) (no payment if $10.00 or less) …………………….                                                                                       12 
      13. IF OVERPAYMENT: (Indicate Below Credit to Next Year and/or Refund)                                                                                                                                 
                   13A  CREDIT TO NEXT YEAR ………………………………………………………………………………..                                                                                                               13A               
                   13B  REFUND  (no refund if $10.00 or less) ….………………………………………………………...                                                                                                   13B               
  SECTION        B — DECLARATION            OF ESTIMATED TAX                                                                                                                                                 
    14. INCOME SUBJECT TO TAX x 1.75%                 ………………………………………………………………………………                                                                                                       14                
    15. QUARTERLY AMOUNT DUE  (1/4 of Line 14)                   ………………...………………………………………………….                                                                                             15                
    16. CREDIT FROM 13A          ………………………………………………………………………………………………….                                                                                                                    16                
    17. Line 15   Line-  16 (Amount of Estimated Tax being paid with this Return)      ……………………………………………………………...                                                                                           17 
 Please18. TOTALattachOF THIScopiesPAYMENTof(Lineall12appropriate+ Line 17) ………………...……………………………………………………………………….Federal Return and Supporting Schedules.                                                   18 
  SIGNATURE                                                                                                                                                                                                  
   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.         
                                                                                                                                                                               Date 
                   Signature  
  Sign 
                                                                                                                                                                               Email 
  Here             Title 
                                                                                                              Date                                                                                         CONTACT INFORMATION 
  Paid              Preparer s’  
  Preparer s’       Signature                                                                                 Phone Number                                                                                  City of Englewood 
  Use Only                                                                                                                                                                                                  Income Tax Department 
                                                                                                                                                                                                            333 W National Rd 
  Third            Do you want to allow another person to discuss this matter with the City of Englewood? (see instructions)            YES   (complete below)             NO                               Englewood, OH  45322 
                                                                                                                                                  
  Party             Designee’ s                                                                                                                                                                             937- 836- 5106 
  Designee          Name                                                                                        Phone Number                                                                                tax@englewood.oh.us 
   

                                            ALL FEDERAL SCHEDULES LISTED BELOW AND OTHER SUPPORTING DOCUMENTS                                                            
                                                                   MUST BE ATTACHED TO THIS RETURN. 

 SCHEDULE X                    RECONCILIATION WITH FEDERAL INCOME TAX RETURN 

                        ITEMS NOT DEDUCTIBLE                         ADD                                               ITEMS NOT TAXABLE                        DEDUCT 
  A. Capital Losses (including IRC 1221 & 1231 property)      …    $                            N. Capital Gains from sale, exchange or other                  
  B. Expenses attributable to non taxable- income     ……………        $                               disposition (including IRC 1221 $ 1231 property) ………       $ 
  C. City & State Income Taxes & other taxes                                                    O. Interest earned or accrued ………………………………...                 $ 
      based on income …………………………………………...                          $                            P. Dividends ……………………………………………………                             $ 
  D. Net Operating Loss Deduction per Federal Return          …….  $                            Q. Other intangible income (explain)    ………………………...          $ 
  E. Payments to Partners (including former partners)         …….. $                                                                                           
   F. Amounts distributed or set aside for                                                      R. Federal Tax Credits (if expense reduction)  ……………...       $ 
      REIT & RIC investors  ………………………………………                        $                            S. Other Income Exempt from City Tax (explain)  ………….         $ 
  G. Amounts deducted for self employed retirement,                                                                                                            
      health and life insurance plans   ……………………………                $                                                                                           
  H. Special Deduction     ………………………………………….                       $                                                                                           
   I. Rental activities by Partnership, S Corp,- LLC, Trusts  ….   $                                                                                           
   J. Other Expenses not deductible (explain)         ………………..     $                                                                                           
                                                                                                                                                               
 M.   TOTAL ADDITIONS  (Lines A through J) ….….……….                $                            Z. TOTAL DEDUCTIONS (Line N through S)……                      $ 

SCHEDULE      Y                BUSINESS APPORTIONMENT FORMULA                              
Use this schedule if engaged in business in more than one city and you do not have books and records which will disclose with reasonable accuracy what portion of 
the net profits is attributed to that part of the business done within the boundaries of the city or cities involved.         
                                                                                               A. LOCATED          B. LOCATED IN              PERCENTAGE            
                                                                                               EVERYWHERE           ENGLEWOOD                   (B ÷ A)             
STEP 1.      ORIGINAL COST OF REAL & TANGIBLE PERSONAL PROPERTY                             $                    $                                           
             GROSS ANNUAL RENTALS PAID MULTIPLIED BY 8……………....                             $                    $                                            
             TOTAL STEP 1……... ……………………………………………………                                         $                    $                                      %     
STEP 2.      GROSS RECEIPTS FROM SALES MADE AND/OR WORK                                                                                                      
             OR SERVICES PERFORMED………………………………….                                            $                    $                                      % 
STEP 3.      WAGES, SALARIES AND OTHER COMPENSATION PAID………...                              $                    $                                      %     
STEP 4.      TOTAL PERCENTAGES………………………………………..                                             $                    $                                      %     
STEP 5.      AVERAGE PERCENTAGE (divide total percentages by number of percentages used).  Transfer to Line 5 for allocation …………………                                   % 

 SCHEDULE Z                    RECONCILIATION OF WITHHOLDING TAX                            
A.    Total Wages Allocated to Englewood (From Schedule Y step 3 or Federal Return)…...                          $                             
B..   Total Wages Reported on Withholding Tax Reconciliation (W- 3)………………………..                                   $                             
C.    If Lines A and B DO NOT MATCH, Provide a detailed explanation or a billing letter will be sent for the difference: 
       
                                                                   ADDITIONAL REQUIRED INFORMATION 
Has Your Federal Tax Liability for any Prior Year been changed as a result of an examination by the IRS? ...                                            YES    NO    
             List Year(s) _____________________   Has an Amended Return been filed with Englewood?........                                              YES    NO    
Do You have Employees in Englewood? ..……………………………………………………………………………                                                                                     YES    NO   N/A 
Do You use subcontract labor to perform work in Englewood?...…………………………………………………..                                                                      YES     NO  N/A 
                                                                                                                                                        YES     NO  N/A 
Are any employees leased in the year covered in this return? …………………………………………………….. 
                                                                                                                                                             
             If YES please provide the following information about the Leasing Company:                     
                           Name ______________________________________________________ 
                           Address ____________________________________________________