FILE THIS FORM IF Y OU                                   ANTICIPATE OWING 
              APPLICATION FOR EXTENSION OF TIME TO                                                                  BY  THE APRIL DUE DATE. 
                                                                                                                    (SEE NOT E BELOW): 
              FILE LANCASTER CITY INCOME TAX RETURN                                                                 CITY OF LANCASTER, OHIO 
              FOR CALENDAR YEAR ENDING DECEMBER 31,  ____________  OR                                               P.O. BOX 128, 104 EAST MAIN STREET  
                                                                                                                    LANCASTER, OH 43130-0128 
              FISCAL PERIOD ________________ TO ____________________                                                TEL # (7 40) 687-6606 
                                                                                                                    WEBSITE: www.ci.lancaster.oh.us 

   NAME(S)_______________________________________________________________________                                    Account#_______________

   ADDRESS __________________________________________________       Social Security Number or FEIN_____________________ 

   CITY ____________________________ STATE ______  ZIP _________ _        Spouse Social Security Number ____________________ 

                           THIS IS NOT AN EXTENSION OF TIME TO PAY YOUR TAX
   PLEASE NOTE: You DO NOT need to request an extension to file by the April due date; however, a copy of the extension request or a copy of the Federal Extension 
   (4868 or other) request MUST BE attached to the actual return at the time it is filed by the extension due date. 

I request an automatic six (6) month extension of time to file the City of Lancaster Income tax for the year end  ________________

Fiscal year filers enter extended due date  ................................................................................................................_________________

1. Total Lancaster Tax Liability ............................................................................................................................  $  ______ _____________ 

2. Total payments and credits  ............................................................................................................................  $  __________________ _ 

3. Balance due. Subtract Line 2 from Line 1........................................................................................................  $ ___________________ _ 

Complete the declaration of estimated tax due (below) for the next tax year if liability to Lancaster will exceed $200.00 

A. Estimated income subject to Lancaster tax ........................................................................................................  $  __________________ 

   Estimated tax due: 2.30% (.0230) times Line A .................................................................................................. $  _________________

8. Lancaster tax to be withheld by employer  ........................................................................................................ $  _________________

C. Credit allowed for income taxed by other cities (refer to Instructions) ............................................................ $  _________________

D.  DECLARATION OF ESTIMATED TAX DUE (Line A less Lines 8 and C) .................................................................. $ _________________

4. Amount of Declaration due. (Enter 25% of Line D if quarterly, 50% if semi-annually or 100% if annually) ...  $ _________________
   Reminders for Quarters 2, 3 & 4 will be sent to you based upon the declaration and payments made.)

5. Total amount due.  Add Lines 3 and 4 .................................................................................................................................  $ ___________________

SIGNATURE AND VERIFICATION 

Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the best of my knowledge 
and belief, it is true, correct and complete and, if prepared by someone other than the taxpayer, that I am authorized to prepare this form. 

Signature of Taxpayer or Authorized Representative _________________________  Date  _______  

Signature of Spouse  ---------------------------------- Date  ____________ 
INSTRUCTIONS :
   1. Complete this form if you need to pay your final balance due and 1st quarter estimated payment by April due date. 

   2. Be sure to attach copy of extension request or Federal Extension request (4868 or other) to your return at the time of filing. 
   3. Pay the entire amount shown on line 5 above by April due date.

This form does not extend the time to pay taxes.  If you do not pay the amount due by the regular due date, you will owe interest and penalty.  If you wish 
to receive a return copy of the approved request, you must include a self-addressed stamped envelope.