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IR-25

CITY INCOME TAX RETURN FOR

FOR THE YEAR

BEGINNING

ENDING

INDIVIDUALS

Check the appropriate box if:

Your social security number

Name(s) and Current Address

REFUND

(An amount must be placed

in Line 6B for this return to be considered

Spouse’s social security number

a valid refund request.)

(if joint)

AMENDED

tax year

•

Did you change residence during 2002?

YES

N O

Single

If YES, enter date of move

•

Should your account be inactivated?

YES

N O

Married-Filing Joint

If YES, explain

Married-Filing Separate

•

YES

Did you file a City return in 2001?

N O

Employer(s) and address where work performed

GROSS WAGES

Part A

•Occupation or nature of business:

•Trade name:

•City of Residence

LESS FEDERAL FORM 2106

•City of Employment/Income #1

(if applicable - you must attach a copy)

•

City of Employment/Income #2

NET WAGES (enter in Column B below)

•

City of Employment/Income #3

Attach all forms W-2 and applicable Federal schedules and/or documentation - TO BACK

Part B

TAX CALCULATION

A Declaration of Estimated City Tax (form IR-21) is REQUIRED for all individuals whose tax is not fully withheld.

Income from wages, salaries, commissions, etc. list by city in which income was earned or services performed, otherwise list by city of residence. If this is your only source of taxable income,

complete Part B only to determine your tax. Taxpayers engaged in business should not complete Part B until after Parts C, D and E are completed.

Column A

Column B

Column C

Column D

Column E

Column F

Column G

TAX

INCOME FROM WAGES,

INCOME FROM NET PROFITS,

TOTAL NET

TAX DUE

NET TAX DUE

CITY

RATE

LESS TAX WITHHELD (W-2) OR

TAXABLE INCOME

SALARIES, COMMISSIONS,

RENTS AND OTHER TAXABLE

PAID TO CITY WHERE INCOME

ETC. (SEE NET WAGES)

INCOME

WAS EARNED

COLUMBUS

0 1

2.0%

0 6

GROVE CITY

2.0%

0 9

GROVEPORT

2.0%

OBETZ

1 0

2.0%

CANAL WINCHESTER

2.0%

MARBLE CLIFF

1 3

1.0%

BRICE

1 4

(UFR)

1 5

1.0%

LITHOPOLIS

1 6

1.0%

(UFR)

HARRISBURG

*ALTERNATE CITY

*Columbus, Canal Winchester, Grove City, Groveport, Marble Cliff and Obetz residents use ALTERNATE CITY LINE for additional tax due to city of residence as a result of having paid a lesser tax to city of employment (Be

sure to indicate city and tax rate).

**NOTE: residents of Harrisburg and Lithopolis may only take credit for taxes paid or withheld to their resident city (Column F). UFR = Universal Filing Requirement - residents must file a return.

1. TOTAL NET TAX DUE (TOTAL OF COLUMN G)........................................................................................................................................

2. LESS CREDITS FOR DECLARATION PAYMENTS AND OVERPAYMENT FROM PRIOR YEAR RETURN ONLY (NOT W-2)

3. BALANCE DUE (LINE 1 LESS LINE 2).

...................................................

If Line 2 is greater than Line 1, enter amount (in brackets) here and carry to Line 6.

4. PENALTY: 10% $_____________ + INTEREST .50% PER MONTH $_____________ + LATE FEE $_____________ = ................................

(see instructions)

....................................................................

TOTAL AMOUNT DUE (ADD LINES 3 AND 4). NOTE: NO PAYMENT IS DUE IF AMOUNT IS LESS THAN $1.00

6. OVERPAYMENT CLAIMED (IF LINE 2 EXCEEDS LINE 1) .................................................................................

A. Enter the amount from Line 6 you want CREDITED to your next year tax estimate..............

B. Enter the amount from Line 6 you want REFUNDED (must be greater than $1.00)

(COMPLETE

Part C

INCOME FROM SOURCES OTHER THAN WAGES, SALARIES, COMMISSIONS, ETC.

REVERSE SIDE OF

FORM FIRST)

CITY

Column H

Column I

Column J

Column K

INSERT APPLICABLE CITIES

INCOME (OR LOSS) FROM

RENTAL INCOME (OR LOSS) FROM

OTHER INCOME FROM

TOTAL OTHER INCOME

BELOW

PART D, PAGE 2 OR SCHEDULE Y

PART E (SECTION 1), PAGE 2

PART E (SECTION 2), PAGE 2

(OR LOSS)

If net result of Column K is a loss, enter zero in Column C

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 are the same as used for Federal income

tax purposes, and understands that this information may be released to the tax administration of the city of residence and the I.R.S.

Has your Federal tax liability for any prior year been changed in the year covered by this

Due on or before April 15th.

See instructions for penalty, interest and late filing fees.

return as a result of any examination by the Internal Revenue Service?

YES

NOTE: DO NOT SEND CASH THROUGH U.S. MAIL.

If YES, has an amended City return been filed for such year or years?

YES

Make checks payable to:

City Treasurer

Mail to: