Return of Income Tax Withheld                                    FOR THE MONTH(S) ENDING
               City of Lakewood                 W-1
               Division of Municipal Income Tax
                                                                                                     DUE ON OR BEFORE
               12805 Detroit Avenue
               Lakewood, Ohio 44107             Make Checks Payable To
               216.529.6620                     City of Lakewood-Division of Municipal Income Tax
               www.onelakewood.com              LINES 1, 2 AND 5 MUST BE COMPLETED
Federal ID No.                                  1. Total Wages Subject to Withholding Tax            $ 
                                                2. Line 1 x 1.5% (see instructions)                                       $ 
                                                3. Total Wages Subject to Residence Tax              $ 
                                                4. Line 3  x 1% (see instructions)                                        $ 
                                                5. Adjustments                                                            $ 
                                                6. Balance Due (total of Lines 2, 4, and 5)                               $ 
                                                                                           I CERTIFY THAT THE INFORMATION ON THIS RETURN
                                                                                           IS TRUE, CORRECT, AND COMPLETE.
Monthly Return Quarterly Return
                                                                                           SIGNATURE   TITLE
Initial Return Final Return    Amended Return   
Notify the Division of Municipal Income Tax of any change in ownership or name and address.
                                                                                           PHONE       DATE

                                      Instructions for Completion of FORM W-1
It is required that on or before the fifteenth (15th) day of each month, taxes withheld from the previous month be paid and FORM W-1 be filed. However, if the amount
withheld is less than $200.00 per month, the employer may defer the filing and payment of FORM W-1 until the last day of the month following the last day of each
calendar quarter. It is important that if you have no taxes withheld for the City of Lakewood for the period listed on the front of the return, that a zero (0) return be filed
to keep files current.
Please check the appropriate box on the front of the FORM W-1 to designate whether this is a monthly, quarterly, or amended return. Please fill in the time period.
Line 1                Place the amount of total wages, salaries, commissions, etc., subject to withholding tax for the City of Lakewood on line 1. Do not include
                      income from individuals under 18 years of age.
Line 2                Place the amount of municipal taxes withheld for the period on line 2. The Lakewood tax rate is 1.5% or .015.
Line 3                Place the amount of total wages, salaries, commissions, etc., for which residence tax was withheld on Line 3. Residence tax is a courtesy to
                      your employees. Note: This is in addition to any required tax withheld for the city of employment.
Line 4                Place the amount of residence tax withheld for the period on Line 4. The Lakewood residence tax rate is 1% for employees working in 
                      employment cities with 1% or greater withholding tax.
Line 5                This line should be used for the correction of errors on previous months for this calendar year. Attach a typed or printed letter explaining the
                      adjustments.
Line 6                Add Lines 2, 4 & 5 and place the total on Line 6. This is the amount of tax due.
                      MAKE CHECK OR MONEY ORDER PAYABLE TO "City of Lakewood - Division of Municipal Income Tax" AND ENCLOSE
                      WITH W-1. RETAIN A DUPLICATE FOR YOUR RECORDS.
INITIAL RETURN:       Complete all information requested on the front of FORM W-1. Double check that you have listed the correct Federal I.D. #, name & mailing
                      address. Please check the Initial Return Box.
FINAL RETURN:         If you sell your business, please advise in writing, to whom and the date the business was sold. File FORM W-1 paying any withholding tax due.
                      Please remember to file FORM W-3 "Reconciliation of Income Tax Withheld" due the last day of February following the end of the calender year.
                      Please check the Final Return Box.
                      FOR ADDITIONAL INFORMATION CALL: 216-529-6620