City of Lakewood-Division of Municipal Income Tax
                                                12805 Detroit Ave., Suite1
                                                    Lakewood, OH  44107
                                      Telephone:   (216) 529-6620  Fax:  (216) 529-6099
                               Website: www.onelakewood.com              Email: taxdept@lakewoodoh.net

                  Form L-ES–Declaration of Estimated Tax for Individuals

                                                Tax Year: ___________

Per Lakewood Ordinance §128.1303 and 128.1304, taxpayers owingtwohundred dollars ($200.00) or more of estimated
tax are required to file a declared estimate of income tax on or before the April filing deadline, or within four (4) months
of the date thetaxpayer becomes subject to tax for the first time.

                  _________                                                                    _________
Primary Social Security Number                                           Spouse Social Security Number
_________________________________________                                _____________________________________________
Primary Last Name              First Name           Initial              Spouse Last Name               First Name          Initial
__________________________________________                               _________________            _ ____       ______________
Present Address                           Apt. #                         City                         State        Zip Code

ESTIMATED TAX CALCULATION

1. a. Total taxable income for current tax year                          $____________

   Prorated Income (use this calculation if lived in Lakewood part of the year)
   b. Annual income Line 1a / 12 months = $______________
   c. Monthly income Line 1b x _______ months in Lakewood = $____________
   Enter the applicable amount on Line 1 from Line 1a or Line 1c                                      1. ___________________
                                                                                                        (Line 1a or Line 1c)

2. Does your employer withhold income tax for the city you work in                                    2. ___________________
   YES–enter 1% or .01 on Line 2
   NO–enter 1.5% or .015 on Line 2

3. Multiply Line 1 by Line 2. Enter amount on Line 3. This is your estimated income                   3. ___________________
   tax for the entire year. If this amount is lessthan$200–STOP,no estimate required.

4. Multiply Line 3 by 25% or 0.25.                                                                    4. ___________________

5. Estimated income tax payments are BILLED quarterly on the following dates:                         5. ___________________
                                                                                           th
   March 1stth    MayDue June15th15th     AugustDue September15th15th DueNovemberDecember1515th
   Due April 15

   Circlethe dates that already passed as of the date you are completing this form and
   enter the number of the dates circled above on Line 5.

6. Multiply Line 4 by Line 5. Enter the amount on Line 6. This is the amount due with                 6. ____________________
   this form.

I hereby declare the information supplied above to be true, correct and complete.

Primary Signature_________________________________________________                             Date _________________________

Spouse Signature__________________________________________________                             Date _________________________

                  Mail completed form to the above Lakewood address or fax to: (216)529-6099

              INSTRUCTIONS FOR FORM DECLARATION OF ESTIMATED TAX

Per Lakewood Ordinance §128.1303 and 128.1304, taxpayers owing one hundred dollars ($200.00) or more of
estimated tax are required to file a declared estimate of income tax on or before April 15 or withinthfour (4)
months of the date thetaxpayer becomes subject to tax forthe first time.

1. a. Enter the amount of total taxable income for the year. This includes income from wages, business
income,distributive income from businesses, rental property, gambling winnings etc.

UTILIZE THE FOLLOWING LINES ONLY IF YOU MOVED INTO LAKEWOOD DURING THE YEAR
b.Calculate your monthly income. Divide Line 1a by 12 months.
c. Calculate your total income for the time living in Lakewood. Multiply Line 1b by the months living in
Lakewood.

Enter the applicable amount on Line 1 from Line 1a or Line 1c.

2. Enter the applicable percentage or decimal on Line 2.

3. Multiply Line 1 by Line 2. Enter the amount on Line 3. This is your estimated income tax for the entire
year. If this amount is less than $200 – stop – per Lakewood Ordinance §128.1303 no estimated tax
declaration is required.

4. Multiply Line 3 by 25% or .25. Enter the amount on Line 4.

5. Estimated income tax is billed by the City on a quarterly basis once a declaration of estimated tax has
been filed withour office. To ensure your declared estimate is entered the billing cycle at the appropriate
time circle the dates that already have passed as of the date you are completing this form. Enter the
number of dates circled on Line 5.

6. Multiply Line 4 by Line 5. Enter the amount on Line 6. This amount is due with this form. If the amount
is zero,there are no monies due at this time and upon submission of this form to our office your declared
estimate will beentered into the billing cycle.

In all cases where the taxpayer is required to file an estimated tax declaration, the taxpayer must provide his/her
socialsecurity number, name, and address.

This declaration form is not valid and will not be processed without the taxpayer’s signature and date.