INCOME TAX DEPARTMENT               CITY OF ASHTABULA       Method of Payment
CITY OF ASHTABULA      QUARTERLY ESTIMATE PAYMENT COUPON
4717 MAIN AVE., STE. A                     1ST QUARTER      · Cash (In Office Only)
ASHTABULA OHIO 44004
                                                            · Check or Money Order
                                           Due on or Before   (Payable to "City of Ashtabula")
Taxpayer Soc. Sec. #   Spouses Soc. Sec. # 4-15-202    4
                       Name & Address                       · Visa, Master Card, Discover & Debit Card
                                                              (2.65% Convenience/Service Fee Rate)

                                                              AMOUNT PAID          $ _______.____

INCOME TAX DEPARTMENT               CITY OF ASHTABULA       Method of Payment
CITY OF ASHTABULA      QUARTERLY ESTIMATE PAYMENT COUPON
4717 MAIN AVE., STE. A                     2ND QUARTER      · Cash (In Office Only)
ASHTABULA OHIO 44004
                                                            · Check or Money Order
                                           Due on or Before   (Payable to "City of Ashtabula")
Taxpayer Soc. Sec. #   Spouses Soc. Sec. # 6-15-2024
                       Name & Address                       · Visa, Master Card, Discover & Debit Card
                                                              (2.65% Convenience/Service Fee Rate)

                                                              AMOUNT PAID          $ _______.____

INCOME TAX DEPARTMENT               CITY OF ASHTABULA       Method of Payment
CITY OF ASHTABULA      QUARTERLY ESTIMATE PAYMENT COUPON
4717 MAIN AVE., STE. A                     3RD QUARTER      · Cash (In Office Only)
ASHTABULA OHIO 44004
                                                            · Check or Money Order
                                           Due on or Before   (Payable to "City of Ashtabula")
Taxpayer Soc. Sec. #   Spouses Soc. Sec. # 9-15-2024
                       Name & Address                       · Visa, Master Card, Discover & Debit Card
                                                              (2.65% Convenience/Service Fee Rate)

                                                              AMOUNT PAID          $ _______.____

INCOME TAX DEPARTMENT               CITY OF ASHTABULA       Method of Payment
CITY OF ASHTABULA      QUARTERLY ESTIMATE PAYMENT COUPON
4717 MAIN AVE., STE. A                     4TH QUARTER      · Cash (In Office Only)
ASHTABULA OHIO 44004
                                                            · Check or Money Order
                                           Due on or Before   (Payable to "City of Ashtabula")
Taxpayer Soc. Sec. #   Spouses Soc. Sec. # 1-15-2025
                       Name & Address                       · Visa, Master Card, Discover & Debit Card
                                                              (2.65% Convenience/Service Fee Rate)

                                                              AMOUNT PAID          $ _______.____