Due by April 15th or                     APPLICATION FOR EXTENSION OF TIME TO FILE                                                                           For taxable 
3½ months from fiscal year end                                                                                                                               year ending: 
                                                             City ______________________ 
                                                                                                                                                            File with: 
Taxpayer Name(s) ____________________________________________                           Account Number _______________________________                      Vandalia Tax Office 
                                                                                                                                                            PO Box 727 
Address ____________________________________________________                            SSN(s) or FID # ________________________________                    Vandalia, OH 45377 
City _______________________________________________________                            State ______________     Zip Code _________________                 FAX: (937) 415-2361 
                                                                                                                                                             
                                            TAX RATE 
     ESTIMATED TOTAL                  (2% Vandalia; 2% Brookville; 1% Butler Twp                               LESS: OVERPAYMENT AND/OR 
     TAXABLE INCOME                           JEDZ)                                   ESTIMATED TAX DUE            PRIOR PAYMENTS                           NET TAX DUE 
                                                                                                                                               
An extension of __________ days for filing the City income tax return for the year shown above is requested.  
By signing below, I declare that the extension requested herein for filing the income tax return for Vandalia, Brookville and/or the Butler Township JEDZ is necessary, that I am authorized to sign this request, and that the 
estimated tax amounts shown above are true and complete to the best of my knowledge. 
Signature of Taxpayer _____________________________________________________________  Date _____________________________  Title (if officer of corporation) ___________________________________ 

                                                                                      TAXABLE ITEMS 
• Wages, salaries and other compensation                                                      • Employer provided educational assistance and/or reimbursement (taxable to  
• Commissions, fees and other earned income                                                     the same extent as for federal taxation) 
• Sick pay; Vacation pay; Holiday pay                                                         • Royalties, if not derived from intangible property 
• Bonuses, stipends and tips                                                                  • Employer paid premiums for group term life insurance (taxable to the same  
• Employer supplemental unemployment benefits (SUB pay)                                         extent as for federal taxation) 
• Director fees                                                                               • Compensation paid in goods or services or property usage (taxed at fair market  
• Strike pay                                                                                    value) or excess employee discounts 
• Employee contributions to retirement plans and tax deferred annuity plans                   • Prizes and gifts if connected with employment 
  (including Sec. 401(k), 403(b), 457, etc.)                                                  • Income from guaranteed annual wage contracts 
• Profit sharing                                                                              • Income from jury duty 
• Income from wage continuation plans (including retirement incentive plans,                  • Executor fees 
  severancepay  and golden parachute payments)                                                • Union steward fees 
• Pre-retirement distributions from retirement plans                                          • Net profits of businesses, professions, sole proprietorships, joint ventures, 
• Income from partnerships, estates or trusts                                                   partnerships, corporations, LLCs, etc. 
• Contributions made on behalf of employees to tax deferred annuity programs                  • Ordinary gains as reported on Federal Form 4797 
• Uniform, automobile, moving and travel allowances                                           • Income received as a result of a covenant not to compete 
• Reimbursements in excess of deductible expenses                                             • Stock options 
• Employee contributions to costs of fringe benefits                                          • Gambling and lottery winnings 
• Net rental income                                                                            
• Net farm income 
 
                                                                                    NON-TAXABLE ITEMS          
• Interest income                                                                             • Active duty military pay (including National Guard and Reserves when on  
• Dividends                                                                                     active duty) 
• Capital gains                                                                               • Educational scholarships unless subject to federal taxation 
• Social Security                                                                             • Housing allowances for the clergy to the extent that the allowance is used to  
• Income from federally qualified retirement or pension plans                                   provide a home 
• Earnings of persons under 18 years of age                                                   • Health and welfare benefits distributed by governmental, charitable, religious  
• State unemployment benefits                                                                   or educational organizations 
• Worker’s compensation                                                                       • Proceeds of sickness, accident, liability, or life insurance policies 
• Court ordered child support                                                                 • Compensatory insurance proceeds derived from property damage or personal  
• Alimony                                                                                       injury settlements 
• Annuity distributions                                                                       • Disability payments received from private industry or local, state or federal 
• Prizes or gifts not connected with employment                                                 governments or from charitable, religious or educational organizations 
• Patent and copyright income                                                                 • Compensation for serving as a precinct election official under $1,000     
• Royalties derived from intangible income                                                     
                                                                                               
                        This list is for informational purposes only.  It may not be all-inclusive and is subject to revision without notice. 
                                       For items not listed, contact the Income Tax Office for clarification at (937) 415-2240. 

                                EXTENSIONS 

Applications for extensions should be received or postmarked by the due date of the return. 
Extensions may be granted on an automatic basis if an automatic six-month extension was    
requested for filing the federal income tax return.  A copy of the federal extension must         
accompany the municipal income tax return when filed by the extended due date. 
Penalty and interest may be imposed on any tax balance remaining unpaid after the due date.  
For additional information, see the General Information/Instruction sheet available at 
www.vandaliaohio.org.