Form R - Xenia City Income Tax - 2001
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1
22001 - XENIA CITY INCOME TAX - 2001
DIVISION OF TAXATION
Page 3
101 N. Detroit St.
Form R
P O Box 490
Fiscal Year Begin___/___/2001 End___/___/2002
Xenia, OH 45385-0490
*If ALL your taxable earnings are reported
(937) 376-7248
DUE ON OR BEFORE APRIL 30, 2002
on W-2 forms, only the Lines marked with
FAX (937) 374-1818
LATE FILING OF THIS RETURN SUBJECTS YOU
an asterisk (*) need be completed.
WEB:
TO INTEREST AND A MINIMUM $25.00 PENALTY
WILL THIS BE YOUR FINAL RETURN FOR THE CITY OF XENIA?
RESIDENCY STATUS-Check one MARITAL STATUS-Check one
TAXPAYERS SSN, NAME(S) & ADDRESS (CORRECT IF NECESSARY)
____Resident
____Single
____Non-resident
____Married
(
) Filing separately
____Partial year resident
____Separated
From______________To_______________
Social Sec. No._____-____-_______ Spouse_____-____-_______
Fed. ID No.(Businesses)_____ _________________
IF YOU HAD NO TAXABLE INCOME FOR 2001, PLEASE CHECK
REASON BELOW:
Taxpayer Spouse (W)
Unemployed (Entire year) . . . . . . . . . . . . . . . . . .
Retired . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Social Security Disability . . . . . . . . . . . . . . . . . . .
You must obtain a Xenia extension if a Federal extension has been granted. This
ADC/General Relief . . . . . . . . . . . . . . . . . . . . . . .
extension must be requested prior to the due date of the return.
Other (explain) __________________ . . . . . . . .
WAGES*
EMPLOYER
XENIA TAX W/H
OTHER CITY TAX W/H
GROSS WAGE AMT.
TAX OFFICE USE ONLY
)
Do not use this space
*
Not to exceed 1.5% (See Pg 2
Please complete this section--one line for each W-2*
Attach
all
W-2's
Here
1*
TOTAL WAGES AND WITHHOLDING
1A
1B
1C*
LESS EMPLOYEE BUSINESS EXPENSES. Copies of Federal return (1040), Schedule A and
1D(
)
(
)
2106 must be attached.
Work sheets will not be
accepted.
TOTAL WAGES (1C less 1D). . . . . . . . . . . . . *1E
OTHER INCOME
2. INCOME OTHER THAN WAGES FROM SCHEDULE W (Page 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
Do NOT subtract business losses (Line 2) from wage income (Line 1C)
3. ADJUSTMENT FROM SCHEDULE X (Page 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
4. TOTAL INCOME (Line 1 + Line 2 or Line 2 +/- Line 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
5. AMOUNT ALLOCABLE TO XENIA (if Schedule Y -Page 4- is used _____% . . . . . . . . . . . . . . . . . . . . . . .
5
6* TOTAL TAXABLE INCOME (Line 1E, 4 or 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . *
6
7* TOTAL TAX DUE (1.75% of Line 6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . *
7
TAX CREDITS
8* CREDITS:
(A) Xenia tax withheld (From Line 1A) . . . . . . . . . . . . . . . . . . . . . .
(A)
W-2
G
(B) Estimate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(B)
A
G
C
G
(C) Tax paid to other cities (From Line 1B) . . . . . . . . . . . . . . . . . .
(C)
E
G
F
G
Do not include amounts refunded to you!
K(1)
G
(D) TOTAL CREDITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . *8(D)
1040
G
1065
G
9* TAX DUE - Net (Line 7 less Line 8-D) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . *
9
1099
G
10. Penalty $____________Interest (After May 1, 2002) $____________ . . . . . . . . . . . . . . .
10
1120(S) G
2106
G
4797
G
11* TOTAL AMOUNT DUE (Make check payable to the City of Xenia) . . . . . . . . . . . . . . . . . . *
11
8825
G
Amounts less than $2.00 need not be paid. (Return
be filed.)
MUST
Misc.
G
12. OVERPAYMENT (Line 8-D less Line 7) . . . . $
Credit to next year's tax. . . . . . . . . . . . . $
Refund $
Amt. Rec'd
Overpayments less than $2.00 will not be refunded or credited.
G Cash G Check G M/O G Visa/MC
IMPORTANT:
All Federal Schedules (including “Statements”, if any)
be attached. Returns received without
complete Schedules will be marked
MUST
ALL
"INCOMPLETE" and returned to the taxpayer, along with any remittance enclosed with the return. A
"
"
N
INCOMPLETE
RETURN IS NOT A FILED
! Completed returns must be received by May 1, 2002 to avoid penalty and interest charges.
RETURN AND CAN CAUSE LATE PENALTY CHARGES
The undersigned declares that this return (and accompanying schedules) is a true, correct and complete return for the taxable period stated. Tax preparer is authorized to
disclose information concerning this tax return to the Xenia tax office.
Signature of Taxpayer or Agent
Title
Date
Signature of person preparing return or keeping books
Date
Signature of Spouse
Date
Address
Phone No.
Pre-Audited by
Date
Audited by
Date
File Date
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