Commissioner of Taxation
                                          TAX YEAR                CITY OF WAUSEON                                                                                                            230 Clinton St.
                                                                                   INCOME TAX RETURN                                                               MAIL TO
                                                                                                                                      OR THE IRS                                             Wauseon, OH 43567
                                                                  DUE ON OR BEFORE APRIL 15 DUE DATE
                                                                  Or within three months and fifteen days after the close of a fiscal year or period.
                                          FOR CALENDAR YEAR ENDING DECEMBER 31                                                                                                               OFFICE USE ONLY
                                          OR FOR THE MONTH ENDING                                                                                                                            AMOUNT PAID
                                                                                                                                                                                             CHECK NO.
                                                                                                                                                                                             CASH RECEIPT NO.
                                                             ACCOUNT NO.                  SOCIAL SECURITY NO. OR E.I.D. NO.                                                                  REFUND □
                                                                                                                                                                                             CARRY OVER □
                                                                                                                                                                                             AUDIT DATE
                                          NAME (S) __________________________________________________________________________                                                                FINAL RETURN? □ YES
                                          ADDRESS _________________________________________________________________________
                                                     _________________________________________________________________________
                                                                                                                                                                   □ CHECK BLOCK IF ADDRESS CHANGE
                                          EMAIL ____________________________________________________________________________                                                                 Moved into City
                                          PHONE __________________________________                                                                                                           Moved Out of City
                                                                                                                                                                   PHONE: (419) 335-1171 FAX: (419) 335-0063 
                                                                                                                                                                   Our website is www.cityofwauseon.com
                                          1. COMPENSATION FROM WAGES - ATTACH W-2’S
                                                                                                                                                     Wauseon          Other City Tax Withheld
                                              NAME OF EMPLOYER                           TAXPAYER OCCUPATION                          A.             Tax Withheld  B. 11/2% LIMITATION                                         GROSS WAGES

                                          IF ALL YOUR INCOME IS FROM W-2 WAGE & TAX STATEMENTS ATTACHED, PUT TOTAL GROSS EARNINGS AMOUNT ON
                                          LINE 1 AND ON LINE 11 TO COMPUTE TAX                                                                                                                                                 1.             .
                                          2. Income from self-employment (Attach Federal Schedule ‘C’, ‘E’ & ‘K-1s’) ........................................................................................                  2.             .
                                          3. Income from rents, leases, or farm income   (Attach Federal Schedules ‘E’, & ‘F’) .............................................................................                   3.             .
                                          4. Partnership income   (Attach Federal Form 1065, K-1s, or 8825 where applicable) ..........................................................................                        4.             .
                                          5. Corporation income   (Attach Federal 1120, 1120S, 1120A, including Other Income & Deduction Schedules) ..............................                                             5.             .
                                          6. Misc. income (Attach 1099’s or explain source) Do not include Dividends, Interest, Unemployment or Worker's Compensation ...                                                      6.             .
                                          7. Additions to income (From Section A, Line 26 on Page 2).....................................................................................................................      7.             .
                                          8. Deductions from income (From Section B, Line 31 on Page 2)(see instructions for losses).                    ...............................................................       8.().
                                          9. Adjusted net income (Add Lines 1 thru 8) ..............................................................................................................................           9.             .
                                          10. Percent of Line 9 allocable to Wauseon if allocation formula is used from
                     ATTACH W-2 FORMS HERE
                                              section Y, Line 35 on page 2               % x Line 9 (at least four decimal places)...........................................................................                  10.            .
                                          11. Total income subject to Wauseon income tax ..................................................................................................................................... 11.            .
                                          12. WAUSEON INCOME TAX AT 11/2% (.015) OF AMOUNT ON LINE 11 ..........................................................                                                               12.            .
13A. CITY TAX WITHHELD PER W-2 FORMS (11/2% LIMITATION) (Total of columns 1A & 1B)..........................                                                                    13A. (.)
13B.                                          Tax on income with no withholding. Paid or Due City of   (Not to Exceed 1.5%) (Attach copy of return) ...13B.                          (.)
13C. Estimated tax paid this city and prior year overpayment ..................................................................................13C.                                  (.)
                                          14. TOTAL CREDITS ...........................................................................................................................................(Lines 13A + 13B + 13C) 14.            .
                                          15. BALANCE OF TAX DUE (Amounts under $10.00 are not due nor refundable nor credited to next tax year.)(Line 12 less Line 14).... 15.                                                               .
                                          16. OVERPAYMENT (IF TAX CREDITS EXCEED TAX DUE, ENTER DIFFERENCE)................................................................................ 16.                                               .
                                          17. UNDERPAYMENT PENALTY (MULTIPLY LINE 15 BY 15%) ................................................................................................................. 17.                            .
                                          18. LATE FILING FEE $25.00 AND UP TO $25.00 PER MONTH THAT RETURN IS LATE, UP TO $150.00 MAXIMUM........................                                                             18.            .
                                          19. INTEREST OF LINE 15 (SEE WEBSITE FOR %)     , REGARDLESS OF EXTENSION ..........................                     ..............................................              19.            .
                                          20. TOTAL TAX, PENALTIES & INTEREST DUE (LINES 15, 17, 18 & 19) Make check payable to COMMISSIONER OF TAXATION .... 20.                                                                             .
                                              PAYMENT IN FULL MUST ACCOMPANY TAX RETURN TO COMPLETE FILING REQUIREMENTS.
                                          21. IF LINE 16 IS AN OVERPAYMENT, INDICATE THE AMOUNT TO BE CREDITED TO THE NEXT TAX YEAR (         .          )
                                              OR THE AMOUNT TO BE REFUNDED (         .          )
                                          TAX PREPARER       (Other than Taxpayer)                                                    TAXPAYER
                                              MUST                                                                                    MUST                        X
                                          SIGN HERE          (Signature of Tax Preparer)                    (Date)                    SIGN HERE                   (Signature of Taxpayer)                                                      (Date)
                                          (Print name)
                                                                                                                                                                  X
                                          (Firm & Phone No.)                                                                                                      (Signature of                                                      Taxpayer)       (Date)
                                          (Address)                                                                                   Check the box next to your signature to authorize us to speak directly to your preparer regarding your return.
                                              THIS BOX FOR TAX PREPARER USE ONLY

                                        PAGE 2

                                SECTION A - ADDITIONS TO INCOME
22. GUARANTEED PAYMENTS TO PARTNERS....................................................................................................................................      22.        .
23. INCOME TAXES TAKEN AS A DEDUCTION ON LINES 2, 3, 4, OR 5 ON PAGE 1 ........................................................................                              23.        .
24. EXPENSES ATTRIBUTABLE TO THE PRODUCTION OF NONTAXABLE INCOME. AT LEAST 5% OF SECTION B-LINE 31 .....                                                                     24.        .
25. CONTRIBUTIONS IN EXCESS OF 10% OF NET PROFITS, SOLE PROPRIETOR KEOUGH, 401(k), OR SIMILAR PLANS;
OTHER EXPENSES NOT CONSIDERED ORDINARY AND NECESSARY .....................................................................................                                   25.        .
26. TOTAL ADDITIONS TO INCOME (Add Lines 22-25) - TRANSFER TO LINE 7 ON PAGE 1 ...........................................................                                   26.        .

                                SECTION B - DEDUCTIONS FROM INCOME
27. DEDUCT INTEREST INCOME INCLUDED IN ENTITIES SHOWN ON PAGE 1, LINES 2-5...........................................................                                        27.        .
28. DEDUCT DIVIDEND INCOME (LESS FEDERAL EXCLUSIONS) ....................................................................................................                    28.        .
29. DEDUCT INCOME FROM PATENTS AND COPYRIGHTS...............................................................................................................                 29.        .
30. OTHER DEDUCTIONS - DESCRIBE (NOL) ATTACH DOCUMENTATION.
                                                                                                                                                                             30.        .
(CITY CODIFIED TAX ORDINANCE DOES NOT ALLOW FEDERAL SCHEDULE A (ITEMIZED DEDUCTIONS) FOR 
UNREIMBURSED EMPLOYEE BUSINESS EXPENSE BASED ON FEDERAL 2106 FORM.)
31. TOTAL DEDUCTIONS FROM INCOME (Add Lines 27-30) - TRANSFER TO LINE 8 ON PAGE 1 .................................................                                          31.        .

                                SECTION C - PARTNERSHIP INCOME
32. NAME AND ADDRESS OF PARTNERSHIP AND EID NO. (Attach K-1’s and Schedule E)
                                                                                                             $
                                                                                                             $
TOTALPARTNERSHIP INCOME - TRANSFER TO LINE 2, PAGE 1...............................................................................................                          32.        .

SECTION D - PARTNER’S DISTRIBUTIVE SHARE OF PARTNERSHIP INCOME
33. TO BE COMPLETED IF PARTNERSHIP FILES AN INFORMATION ONLY RETURN
Name, Residence, Address, S.S. Number of Each Partner                                   Distributive Share of Each Partner
                                                                                                                       Amount

                                                                                                                                                                             33.
TOTAL LINE 33 TRANSFER TO LINE 4, ON PAGE 1 (attach all forms).........................................TOTAL                                                                            .

                                                      SECTION Y - BUSINESS ALLOCATION
                                                                             a. Located                      b. Located in                                                       c. Percentage
34. BUSINESS ALLOCATION FORMULA                                              Everywhere                       Wauseon                                                            (b ÷ a)

STEP 1 AVERAGE NETBOOK VALUE OF REAL AND
TANGIBLE PERSONAL PROPERTY ..............................
GROSS ANNUAL RENTALS MULTIPLIED BY 8 ............
                                                                                                                                                                                              %
TOTAL STEP 1 ................................................................
STEP 2 WAGES, SALARIES OTHER COMPENSATION                                                                                                                                                     %
FOR SERVICES PERFORMED ......................................
                                                                                                                                                                                              %
STEP 3 GROSS RECEIPTS FROM SALES.................................
                                                                                                                                                                                              %
STEP 4 TOTAL PERCENTAGES ....................................................................................................................................................
STEP 5 AVERAGE PERCENTAGE                                                                                                                                                    35.
(Divide Total Percentages by Number of Percentages Used (at least four decimal places)                                                                                                        %

                                     ESTIMATED PAYMENTS ARE REQUIRED
GENERAL INFORMATION
Any taxpayer having or anticipating a tax liability to the City of Wauseon shall file a declaration of estimated tax and pay the estimated tax due in quarterly installments.
If a taxpayer’s income is from wages and the taxpayer’s employer withholds the proper amount of Wauseon Tax, the taxpayer is not required to file an estimate of Wauseon
Tax due. Joint filing is permitted but each spouse must file an estimate based on their separate income. Complete the estimated Wauseon Tax form for each quarterly
payment. Detach the form and mail it to the address provided. Keep a record of your payments on the worksheet provided.