Individual Tax Return Form - City Of Huber Heights - Division Of Taxation - 2016
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1
2CLEAR FORM
PRINT FORM
City of Huber Heights
Individual Tax Return
Account Number ___________
Division of Taxation
2016
P.O. Box 24309
or
Huber Heights, Ohio 45424
Fiscal Period _____ to ______
Phone: (937) 237-2976
th
Fax: (937) 237-2983
Calendar year taxpayers file on or before April 18
th
th
Website:
Fiscal year due on 15
day of the 4
month after year end
Name
SSN
CHECK ONE
□ Single
□ Married Filing Joint
Spouse Name
SSN
□ Married Filing Separate
Address
City/State/Zip
Part Year Resident From _____to ____
PART
I am not required to complete Part B because: Check One
□ All income from non-taxable source (list source): ______________________________________
Previous Address _________________
A
□ Active Duty Military and no other non-military income
□ Retired with only non-taxable income
Date Retired _____________DOB_________________
E-mail __________________________
Phone __________________________
PART B
Tax Calculation
(Attach front page of Federal Form 1040)
0.00
1.
Total Qualifying Wages (W-2 Box 5 – Attach W-2 Form) For multiple W-2s complete Worksheet A on page 2........
$_____________________
2.
Less Employee Deductions (Attach Form 2106 & Federal Schedule A) 2% allowance ……………………………..
$_____________________
0.00
3.
Taxable Wages Before Adjustment. (Line 1 minus Line 2)………………………………………………………………...
$_____________________
4.
Less Non-taxable Income (Part year or non-residents only) (provide calculations) …………………………………….
$_____________________
0.00
5.
Taxable Qualified Wages (Line 3 minus Line 4)…………………………………………………………………………….
$_____________________
6.
Other Income or (Loss) From Federal Schedules C, E, F, K-1, 1099-MISC (See Worksheet B)
0.00
(Attach copies of all Federal Schedules)………………………………………………………………………………….
$_____________________
0.00
7.
Huber Heights Taxable Income (Line 5 plus Line 6) Losses on Line 6 do not offset W-2 income from Line 5……...
$_____________________
0.00
8.
Huber Heights Income Tax (Multiply Line 7 by 2.25%. [.02250])………………………………………………….………
$_____________________
0.00
9.
a. Huber Heights Tax Withheld (Per W-2’s)……………………………………………
$____________________
b. Estimates Paid (Including credit from previous year)………………………………
$____________________
0.00
c. Other Local taxes Paid (Allowed up to 2.25% credit)………………………………
$____________________
0.00
d. Other Local Taxes Paid for Non-W-2 Income (Allowed up to 2.25% credit)……
$____________________
0.00
10. Total Payment and Credits (Line 9a + 9b + 9c + 9d)………………………………………………………………………
$_____________________
0.00
11. Tax Due (Subtract Line 10 from Line 8) (Amounts less than $10.00 not payable)……………………………………..
$_____________________
12. Overpayment – Credit to 2017 (Amounts less than $10.00 will not be credited)…
$____________________
13. Refund (Amounts less than $10.00 will not be refunded)……………………………
$____________________
PART C
Declaration of Estimated Tax For 2017
14. Total Estimated Income Subject to Tax………………………………………………………………………………………
$_____________________
0.00
15. Huber Heights Tax Declared (Multiply Line 14 by 2.25%. [.02250])………………………………………………………
$_____________________
16. Estimated Taxes Expected to be Withheld from Wages…………………………………………………………………...
$_____________________
0.00
17. Tax Due After Withholding (Line 15 less Line 16) STOP if this amount is less than zero………………………………
$_____________________
0.00
18. Declaration Due (25% of Line 17)…………………………………………………………………………………………….
$_____________________
0.00
19. Less Credits (From Line 12 above)………………………………………………………………………………..…………
$_____________________
0.00
20. Net Estimated Tax Due (Line 18 minus Line 19) is greater than zero…………………………………………………….
$_____________________
0.00
21. TOTAL AMOUNT DUE - Combine Line 11 with Line 20 (Make check payable to City of Huber Heights)……….….
$_____________________
*Subsequent estimated payments are due by the 15th of June, September, and December.
The undersigned declares that this return (and accompanying schedules) is a true, correct and complete return for the taxable period stated and that the figures used herein are the same as used for Federal Income Tax purposes.
________________________________________________________________
_______________________
_______________________________________________________________
_____________________
SIGNATURE OF PERSON PREPARING IF OTHER THAN TAXPAYER
DATE
SIGNATURE OF TAXPAYER
DATE
________________________________________________________________
_______________________
_______________________________________________________________
_____________________
NAME AND ADDRESS OF PREPARER
PHONE NUMBER
SIGNATIRE OF SPOUSE
DATE
□
Check here if we may contact the above preparer with questions regarding the preparation of this return.
PAYING TAX DUE BY CREDIT CARD
1. Circle One:
MASTERCARD
VISA
DISCOVER
2. Account Number (16 digits): _____________________
______________________
______________________
_______________________
3. Expiration Date: ______/______ (mm/yy)
4. Verification Code (must be provided to process):_____________5. Tax Due: $________________
6. Convenience Charge: $ ___________ 7. Total Paid: $_______________ 8. Signature for Authorization: _________________________________
We
are now accepting Visa, Mastercard and Discover payments in our office and over the phone for all tax payments. There will be a 2.45% convenience
charge added to all credit card transactions, with a minimum charge of $2.45. Visa debit cards have a flat fee of $3.95.
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