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CCA – DIVISION OF TAXATION 2023
216.664.2070 800.223.6317
www.ccatax.ci.cleveland.oh.us
Individual Municipal
Income Tax Forms

Tax forms due April 15, 2024 eFile with CCA at https://efile.ccatax.ci.cleveland.oh.us
Social Security No.
– –
– –

Read the instruction booklet to determine whether you have taxable income for municipal
income tax purposes.

If you have taxable income, complete and file the City Tax Form.

If you have no taxable income for municipal purposes, complete and file the Exemption Certificate
below.
CCA MEMBER MUNICIPALITIES

Burton Grand Rapids New Carlisle Orwell Shreve
Clayton Grand River New Madison Paulding Somerset
Cleveland Highland Hills New Miami Phillipsburg South Russell
Dalton Linndale New Paris Pitsburg Union
Edon Marble Cliff North Baltimore Riverside Waynesfield
Elida Mentor-on-the-Lake North Randall Rock Creek West Milton
Geneva-on-the-Lake Montpelier Oakwood (Paulding County) Russells Point
Germantown Munroe Falls Obetz Seville
EXEMPTION CERTIFICATE

I LIVE IN A MANDATORY FILING COMMUNITY AND I AM NOT REQUIRED TO PAY MUNICIPAL INCOME TAX BECAUSE:
1. RETIRED, received only pension, Social Security, interest or 4. NO EARNED INCOME FOR THE ENTIRE YEAR
@ dividend income @2023. (Public Assistance, Unemployment, SSI, etc.)
2. MEMBER OF THE ARMED FORCES OF THE 5. BUSINESS CLOSED OR RENTAL PROPERTY
@UNITED STATES FOR THE ENTIRE YEAR 2023. (This does not @
SOLD prior to 1/1/23.
include civilians employed by the military or National Guard.)
3. UNDER 18 FOR THE ENTIRE YEAR 2023.
*@ see reverse for exceptions
IF EXEMPT, COMPLETE, DETACH AND RETURN THE EXEMPTION CERTIFICATE IN THE ENCLOSED ENVELOPE.
KEEP TOP PORTION FOR YOUR RECORDS.
IF YOU ARE NOT FILING THIS EXEMPTION CERTIFICATE, PLEASE DISCARD.
CCA – DIVISION OF TAXATION
205 W SAINT CLAIR AVE 2023 EXEMPTION CERTIFICATE
CLEVELAND OH 44113-1503
SHOW NAME OR ADDRESS CHANGES ON REVERSE.
Name @ Social Security No.
– –
Name of spouse if joint return
– –
Current address Apt. #
City State Zip

I LIVE IN A MANDATORY FILING COMMUNITY AND I AM NOT REQUIRED TO PAY MUNICIPAL INCOME TAX BECAUSE:
1. RETIRED, received only pension, Social Security, Interest or Dividend Income 4. NO EARNED INCOME FOR THE ENTIRE YEAR 2023.
2. @ MEMBER OF THE ARMED FORCES OF THE UNITED @ (Public Assistance, Unemployment, SSI, etc.)
@STATES FOR THE ENTIRE YEAR 2023. (This does not include 5. BUSINESS CLOSED OR RENTAL PROPERTY SOLD prior to 1/1/23.
civilians employed by the military or National Guard.) @
3. UNDER 18 FOR THE ENTIRE YEAR 2023.
@ *see reverse for exceptions Do you authorize your preparer to contact us regarding this return? YES NO
SIGNATURE OF TAXPAYER SIGNATURE OF SPOUSE, PHONE NUMBER SIGNATURE OF PREPARER, DATE @ @
IF JOINT RETURN IF NOT TAXPAYER

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IF YOU ARE NOT FILING THIS EXEMPTION CERTIFICATE,

                              PLEASE DISCARD.

*All individuals who are 18 years of age and older are subject to local income tax.
Note: Montpelier, Munroe Falls, New Paris, Oakwood, Obetz, Phillipsburg, Riverside and
Somerset have no minimum age. Geneva-on-the-Lake uses 15 as a minimum age. Grand
River, and West Milton use 16 as the minimum age. New Carlisle individuals 16 and 17
years old who earn $2,500.00 or more are subject to the tax.

To request a refund complete a City Tax Form and attach the refund worksheet.

                              SHOW NAME AND ADDRESS CHANGES BELOW

Taxpayer Name                                                    Social Security No.
                                                                 –              –
Name of spouse if joint return
                                                                 –              –
Address                             Apt. #                         Move In
                                                                 /           /
City                          State        Zip                     Move Out
                                                                 /           /

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                                                                                                                                                                                                                                     CCA – DIVISION OF TAXATION
                                                                                                                                                                           — Due April 15, 2024                                            216.664.2070  •  800.223.6317
                                                                                                                   2023–City Tax Form                                                                                                   www.ccatax.ci.cleveland.oh.us
                                                                                                                                     90% payment due January 15, 2024                                                    Refund                                               Amended
                                                                                                                               to avoid penalty and interest (see ordinance)                                             Individual                             Joint         Extension Attached
CCA FORM 120-16-IR                                                                                                                                                                                                                               TAXABLE INCOME
                                                                                                Name                                                                                      Social Security No.        1. Employer’s Name                                CITY              INCOME
                                                                                                                                                                                          –              –           a.
                                                                                                Name of spouse if joint return                                                                                       b.
                                                                                                                                                                                          –              –
                                                                                                Current address                                            Apt. #                              Move In               c.
                                                                                                                                                                                          /            /             d.
                                                                                                City, State, Zip                                                                               Move Out              2. Total Wages  Attach W-2s
                                                                                                                                                                                                                                     (          or 1099s  )
                                                                                                                                                                                          /              /
                                                                                                IF MOVED DURING THE YEAR SHOW CHANGES BELOW                                                                          3. Business Income    Attach
                                                                                                                                                                                                                                        Schedule C
                                                                                                PRINT OR TYPE                                                                                                                           (         )
                                                                                                                                                                                                                                        Schedule E
                                                                                                                                                                                          –              –           4.Rental Income  (         Attach         )
                                                                                                                                                                                                                                        Attach
                                                                                                                                                                                          –              –           5.K-1 Income   (             Schedule E & K-1)
                                                                                                                                                                                               Move In
                                                                                                                                                                                          /              /           6. Other Income Source
                                                                                                                                                                                               Move Out                       CITY OF RESIDENCE                                 PHONE NUMBER
                                                                                                                                                                                          /              /                                                                 (     )       –
NOTE:                                                                                                         IF TOTAL WAGES WERE EARNED IN THE SAME CITY YOU LIVED IN AND CITY TAX WAS CORRECTLY WITHHELD, COMPLETE YELLOW SECTIONS ONLY, SIGN, 
                                                                                                              DATE, ATTACH W-2 FORMS AND MAIL RETURN. ALL OTHERS SEE INSTRUCTIONS AND COMPLETE FORM IN ITS ENTIRETY.
                                                                                                              SECTION A              Employment / Profit Tax 2023
                                                                                                              L                COLUMN 1                    COLUMN 2                       COLUMN 3 COLUMN 4            COLUMN 5            COLUMN 6                        COLUMN 7      COLUMN 8
                                                                                                                                                                                                                       Less: Tax
                                                                                                              I            Work City Name                                                 Work                    Withheld (Attach                                         Less: Tax     Tax Due CCA
                                                                                                              N            List Each City                                                 City Tax                      W-2) Or            Less: Prior                     Paid On       (If $10.00 or less 
                                                                                                                                                                                                                                                                           Employment
                                                                                                              E                Only Once                   Taxable Income                 Rate         Tax Due    Paid Other Cities        Year Credit                     Tax Estimate  enter zero)
                                                                                                              9

                                                                                                                   Total each column. Add positive 
                                                                                                              10   figures only in Column 8.
                                                                                                                   If a negative figure is shown in Column 8, enter as credit or refund.           11a     CREDIT                                                  11b REFUND
                                                                                                              11   The credit or refund amount must be greater than $10.00.
                                                                                                              SECTION A-1            Employment / Profit Tax Estimate 2024 (See instructions) – must be completed to receive 2024 Estimated Bills
                                                                                                                                            COLUMN 9                                      COLUMN 10                  COLUMN 11                           COLUMN 12                       COLUMN 13
                                                                                                                                                                                          Estimated                   2023 Credit                                  Balance               Payment Due
                                                                                                                                            Work City                                     Tax Due                 (From Col. 8 only)       (Col. 10 Less Col. 11)                     (¼ of Col. 10 less Col. 11)
                                                                                                              12

                                                                                                              13   Total each column.
                                                                                                              SECTION B              Residence Tax 2023 (Refer to Schedule R Worksheet on reverse of form before proceeding to Line 14)
                                                                                                                               COLUMN 14                   COLUMN 15                      COLUMN 16              COLUMN 17          COLUMN 18                          COLUMN 19         COLUMN 20
                                                                                                                                                                                          Tax Due          Less: Residence                                             Less: Tax Paid    Tax Due CCA
                                                                                                                                                                                                                 Tax Withheld       Less: Prior                        On Residence      (If $10.00 or less 
                                                                                                                           Residence City                  Taxable Income                 Schedule R             (Attach W-2)       Year Credit                        Tax Estimate      enter zero)
                                                                                                              14
                                                                                                              14a
                                                                                                                   Total each column. Add positive 
PLACE CHECK, MONEY ORDER OR CREDIT CARD AUTHORIZATION ON TOP. MUST ATTACH W-2 BELOW REMITTANCE.               15 figures only in Column 20.
                                                                                                                   If a negative figure is shown in Column 20, enter as credit or refund. 16a          CREDIT                                            16b           REFUND
                                                                                                              16 The credit or refund amount must be greater than $10.00.
                                                                                                              SECTION B-1            Residence Tax Estimate 2024 (See instructions) – must be completed to receive 2024 Estimated Bills
                                                                                                                                            COLUMN 21                                     COLUMN 22                   COLUMN 23                                COLUMN 24                 COLUMN 25
                                                                                                                                                                                          Estimated                    2023 Credit                                 Balance              Payment Due
                                                                                                                                     Residence City                                       Residence Tax           (From Line 16a only)        (Col. 22 Less Col. 23)            (¼ of Col. 22 less Col. 23)

                                                                                                              17   Total each column.
                                                                                                                   Tax Due with this return – Add figures shown in last column of Lines 10-13-15-17
                                                                                                              18   Write Taxpayer Identification Number on remittance. Make check payable to CCA - Division of Taxation.
I DECLARE THAT I HAVE EXAMINED THIS RETURN AND ACCOMPANYING SCHEDULES AND STATEMENTS. TO THE BEST OF MY KNOWLEDGE AND BELIEF IT IS TRUE, CORRECT AND COMPLETE. THE FIGURES USED HEREIN ARE THE SAME AS USED FOR FEDERAL INCOME TAX PURPOSES ADJUSTED TO MUNICIPAL INCOME TAX ORDINANCES.
Do you authorize your preparer to contact us regarding this return? YES                                                                                                       NO
                                                                                                              SIGN                   Signature of Taxpayer                 @Signature@ of Spouse, if joint return        DATE              Signature of Preparer, if not Taxpayer        DATE
                                                                                                              HERE
                                                                                                                           NO Payment Enclosed - Mail to:                                 Payment Enclosed - Mail to:                                          Refund Request - Mail to: 
                                                                                                              MAIL         CCA – DIVISION OF TAXATION                                     CCA – DIVISION OF TAXATION                                           CCA – DIVISION OF TAXATION
                                                                                                              TO           PO BOX 94810                                                   PO BOX 94723                                                         PO BOX 94520
                                                                                                                           Cleveland OH 44101-4810                                        Cleveland OH 44101-4723                                              Cleveland OH 44101-4520

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                                                                                                                     ↵               ↵
     CCA – DIVISION OF TAXATION       CREDIT CARD AUTHORIZATION                                                        DETACH HERE

TO CHARGE YOUR INCOME TAX DUE YOU MUST COMPLETE THE FOLLOWING:
                                CHECK ONE       VISA          MASTERCARD          MASTERCARD     AMERICAN EXPRESS       
Taxpayer’s name                                                                                  Taxpayer’s Social Security No.
                                                                                                                    –              –
Cardholder’s name
Cardholder’ addresss                                                              Apt. #
City                            State                                             Zip

                     ACCOUNT NUMBER
                                                                                                 TOTAL AMOUNT CHARGED $ 
                                   EXPIRATION DATE
V CODE
                                                                                                                                    /
                                                                                  CARDHOLDER’S AUTHORIZED SIGNATURE  DATE
                                      MO.        YR.

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      SCHEDULE L                         Schedule of Business and Rental Losses 
 Note: Business and/or rental losses may be carried forward for                                                                                         
 five (5) years. A loss in one city may offset a business or rental         City          YearEnd     Taxable Income   or Loss   Allowable Loss  From Prior YearTotal Adjusted Income 
 gain in the same city. See municipal ordinance for exceptions.                                                                                         
                                                                                                                                                        
 Individuals with net  profit/distributive share  income sourced                                                                                        
 in multiple municipalities with current and/or prior year losses                                                                                       
 refer to the CCA Resident Business/Rental Income Worksheet.                                                                                            
 
                                                                                          SCHEDULE R 
                                                                                     ADJUSTED RESIDENCE CITY PERCENTAGE RATES 
                                                                                 (FIND YOUR WORK CITY RATE IN THE SHADED AREA BELOW) 
      MUNICIPALITY             NO TAX
                               WITH-     .5%     .75%        1%     1.1% 1.12% 1.2% 1.25% 1.4%   1.5% 1.6% 1.65% 1.75% 1.8%       2%  2.1%     2.25% 2.4%    2.5% 2.6% 2.75%   3.0%    
                               HELD 
  Burton                            1    .75     .63         .50    .50  .50   .50   .50  .50     .50 .50     .50      .50 .50    .50      .50   .50   .50   .50      .50 .50   .50 
  Clayton                           1.5  1.25    1.13        1      .95  .94   .90   .88  .80     .75 .75     .75      .75 .75    .75      .75   .75   .75   .75      .75 .75   .75 
  Cleveland                         2.5  2       1.75        1.5    1.40 1.38  1.3   1.25 1.1     1   .90     .85      .75 .70    .50      .40   .25   .10      0     0   0     0 
  Dalton (2023)                     1    .50     .25         0      0    0       0   0        0   0   0       0        0       0  0         0    0     0        0     0   0     0 
  Dalton (2024)                     1.5  1.00    .75         .50    .40  .38   .30   .25  .10     0   0       0        0       0  0         0    0     0        0     0   0        0 
  Edon                         1.75      1.25    1           .75    .65  .63   .55   .50  .35     .25 .15     .10      0       0  0         0    0     0        0     0   0     0 
  Elida                             .75  .75     .75         .75    .75  .75   .75   .75  .75     .75 .75     .75      .75 .75    .75      .75   .75   .75   .75      .75 .75   .75 
  Geneva-on-the-Lake                1.5  1       .75         .50    .50  .50   .50   .50  .50     .50 .50     .50      .50 .50    .50      .50   .50   .50   .50      .50 .50   .50 
  Germantown                        1.5  1.2     1.05        .90    .84  .83   .78   .75  .66     .60 .60     .60      .60 .60    .60      .60   .60   .60   .60      .60 .60   .60 
  Grand Rapids                      1    .75     .63         .50    .50  .50   .50   .50  .50     .50 .50     .50      .50 .50    .50      .50   .50   .50   .50      .50 .50   .50 
  Grand River                       2    1.5     1.25        1      .90  .88   .80   .75  .60     .50 .40     .35      .25 .20    0         0    0     0        0     0   0     0 
  Highland Hills                    2.5  2       1.75        1.5    1.40 1.38  1.3   1.25 1.1     1   .90     .85      .75 .70    .50      .40   .25   .10      0     0   0     0 
  Linndale                          2    1.5     1.25        1      .90  .88   .80   .75  .60     .50 .40     .35      .25 .20    0         0    0     0        0     0   0     0 
  Marble Cliff                      2    1.5     1.25        1      .90  .88   .80   .75  .60     .50 .40     .35      .25 .20    0         0    0     0        0     0   0     0 
  Mentor-on-the-Lake                2    1.5     1.25        1      .90  .88   .80   .75  .60     .50 .40     .35      .25 .20    0         0    0     0        0     0   0     0 
  Montpelier                        1.6  1.10    .85         .60    .50  .48   .40   .35  .20     .10 0       0        0       0  0         0    0     0        0     0   0     0 
  Munroe Falls                      2.25 1.75    1.5         1.25   1.15 1.13  1.05  1    .85     .75 .65     .60      .50 .45    .25      .15   0     0        0     0   0     0 
  New Carlisle                      1.5  1.5     1.5         1.5    1.5  1.5   1.5   1.5  1.5     1.5 1.5     1.5      1.5 1.5    1.5      1.5   1.5   1.5   1.5      1.5 1.5   1.5 
  New Madison                       1    .50     .25         0      0    0       0   0        0   0   0       0        0       0  0         0    0     0        0     0   0     0 
  New Miami                         1.75 1.25    1           .75    .65  .63   .55   .50  .35     .25 .15     .10      0       0  0         0    0     0        0     0   0     0 
  New Paris                         1    .50     .50         .50    .50  .50   .50   .50  .50     .50 .50     .50      .50 .50    .50      .50   .50   .50   .50      .50 .50   .50 
  North Baltimore                   1    1       1           1      1    1       1   1        1   1   1       1        1       1  1         1    1     1        1     1   1     1 
  North Randall                     2.75 2.25    2           1.75   1.65 1.63  1.55  1.5  1.35   1.25 1.15    1.1      1   .95    .75      .65   .50   .35   .25      .15 0     0 
  Oakwood (Paulding County)         1    .50     .25         0      0    0       0   0        0   0   0       0        0       0  0         0    0     0        0     0   0     0 
  Obetz                             2.5  2       1.75        1.5    1.40 1.38  1.3   1.25 1.1     1   .90     .85      .75 .70    .50      .40   .25   .10      0     0   0     0 
  Orwell                            1.5  1       .75         .50    .40  .38   .30   .25  .10     0   0       0        0       0  0         0    0     0        0     0   0     0 
  Paulding                          1.1  1.1     1.1         1.1    1.1  1.1   1.1   1.1  1.1     1.1 1.1     1.1      1.1 1.1    1.1      1.1   1.1   1.1   1.1      1.1 1.1   1.1 
  Phillipsburg                      1.5  1       .75         .50    .50  .50   .50   .50  .50     .50 .50     .50      .50 .50    .50      .50   .50   .50   .50      .50 .50   .50 
  Pitsburg                          1    1       1           1      1    1       1   1        1   1   1       1        1       1  1         1    1     1        1     1   1        1 
  Riverside                         2.5  2.0     1.75        1.5    1.4  1.38  1.3   1.25 1.1     1   .90     .85      .75 .70    .50      .40   .25   .10      0     0   0     0 
  Rock Creek                        1    .50     .25         0      0    0       0   0        0   0   0       0        0       0  0         0    0     0        0     0   0        0 
  Russells Point                    1    1       1           1      1    1       1   1        1   1   1       1        1       1  1         1    1     1        1     1   1     1 
  Seville                           1    1       1           1      1    1       1   1        1   1   1       1        1       1  1         1    1     1        1     1   1     1 
  Shreve                            1    .50     .50         .50    .50  .50   .50   .50  .50     .50 .50     .50      .50 .50    .50      .50   .50   .50   .50      .50 .50   .50 
  Somerset                          1    1       1           1      1    1       1   1        1   1   1       1        1       1  1         1    1     1        1     1   1     1
  South Russell                     1.25 .88     .69         .50    .43  .41   .35   .31  .31     .31 .31     .31      .31 .31    .31      .31   .31   .31   .31      .31 .31   .31 
  Union                             1.5  1       .75         .50    .40  .38   .30   .25  .10     0   0       0        0       0  0         0    0     0        0     0   0     0 
  Waynesfield                       1    .50     .25         0      0    0       0   0        0   0   0       0        0       0  0         0    0     0        0     0   0     0 
  West Milton                       1.5  1.5     1.5         1.5    1.5  1.5   1.5   1.5  1.5     1.5 1.5     1.5      1.5 1.5    1.5      1.5   1.5   1.5   1.5      1.5 1.5   1.5

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SCHEDULE R WORKSHEET - DO NOT INCLUDE INCOME REPORTED ON THE CCA RESIDENT BUSINESS / RENTAL INCOME WORKSHEET
COLUMN 1 COLUMN 2 COLUMN 3 COLUMN 4 COLUMN 5
WORK CITY TAXABLE INCOME RESIDENCE CITY SCHEDULE R TAX RATE RESIDENCE TAX DUE
FROM ABOVE COLUMN 2 TIMES COLUMN 4
%
%
%
**
TOTALS
Enter totals on tax return LINE 14, COLUMN 15 LINE 14, COLUMN 16

SCHEDULE R WORKSHEET INSTRUCTIONS
Do not include income reported on the CCA Resident Business/Rental Income Worksheet.
Column 1 Enter name of your work city. If more than one city, list each city separately. If work city is the same as residence city,
enter name of work city on the ** line.
NOTE: Income earned in same city you live in with employment tax withheld correctly is not subject to residence tax.
Column 2 Enter total income earned in each city listed in Column 1. Add all figures and enter total on front of form on line 14, column 15.
Column 3 Enter name of residence city. If residence city changed during year, prorate Column 2.
Column 4 To locate your adjusted residence tax rate:
(a) Find the WORK CITY RATE in the shaded area of SCHEDULE R.
(b) Follow that WORK CITY column down until you reach the row naming your residence city.
(c) Circle that percentage and enter in Column 4.
Column 5 Multiply Column 2 by Column 4 and enter the tax due. Add all figures and enter total on front of form on line 14, column 16.

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