2018 Individual Municipal Income Tax Forms

1 CCA DIVISION OF MunicipalIncome Tax FormseFile with CCA at Forms due April 15, 2019 Read the instruction booklet to determine whether you have taxable Income for Municipal Income tax you have taxable Income complete and file the City Tax you have no taxable Income for Municipal purposes complete and file the Exemption Certificate below. NameName of spouse if joint returnCurrent addressApt. # CityStateZip Social Security No. CCA MEMBER MUNICIPALITIESAdaAlger BarbertonBratenahlBurtonClaytonCleveland DresdenElidaFrazeysburgMontpelierMunroe FallsNew CarlisleNew MadisonNew MiamiNew ParisNorth Baltimore North Perry VillageNorth Randall NortonOakwood (Paulding County)ObetzOrwellParma HeightsPauldingPhillipsburg Rock CreekRushsylvaniaRussells PointSevilleShreve South Russell TimberlakeUnionWarrensville AlexandriaWest LibertyWest MiltonGates MillsGeneva-on-the-LakeGermantownGrand RapidsGrand RiverHamiltonHighland HillsLinndaleMarble CliffMentor-on-the-LakeEXEMPTION CERTIFICATEI LIVE IN A MANDATORY FILING COMMUNITY AND I AM NOT REQUIRED TO PAY Municipal Income TAX BECAUSE:1.

2 @RETIRED, received only pension, Social Security, interest or dividend incomeMEMBER OF THE ARMED FORCES OF THE UNITED STATES FOR THE ENTIRE YEAR 2018. (This does not include civilians employed by the military or National @UNDER 18 FOR THE ENTIRE YEAR 2018. *see reverse for exceptions4.@NO EARNED Income FOR THE ENTIRE YEAR 2018. (Public Assistance, Unemployment, SSI, etc.) 5.@BUSINESS CLOSED OR RENTAL PROPERTY SOLD prior to 1/1 EXEMPT, COMPLETE, DETACH AND RETURN THE EXEMPTION CERTIFICATE IN THE ENCLOSED ENVELOPE. KEEP TOP PORTION FOR YOUR YOU ARE NOT FILING THIS EXEMPTION CERTIFICATE, PLEASE EXEMPTION CERTIFICATE@SHOW NAME OR ADDRESS CHANGES ON DIVISION OF TAXATION205 W SAINT CLAIR AVECLEVELAND OH 44113-1503 NameName of spouse if joint returnCurrent addressApt.)

3 # CityStateZip Social Security No. I LIVE IN A MANDATORY FILING COMMUNITY AND I AM NOT REQUIRED TO PAY Municipal Income TAX @ @RETIRED, received only pension, Social Security, Interest or Dividend IncomeMEMBER OF THE ARMED FORCES OF THE UNITED STATES FOR THE ENTIRE YEAR 2018. (This does not include civilians employed by the military or National Guard.)UNDER 18 FOR THE ENTIRE YEAR 2018. *see reverse for @@NO EARNED Income FOR THE ENTIRE YEAR 2018. (Public Assistance, Unemployment, SSI, etc.) BUSINESS CLOSED OR RENTAL PROPERTY SOLD prior to 1/1 OF SPOUSE, IF JOINT RETURNDATESIGNATURE OF TAXPAYERPHONE NUMBERDo you authorize your preparer to contact us regarding this return? YES @ NO @SIGNATURE OF PREPARER, IF NOT TAXPAYERIF YOU ARE NOT FILING THIS EXEMPTION CERTIFICATE,PLEASE DISCARD.

4 *All individuals who are 18 years of age and older are subject to local Income : Dresden, Frazeysburg, Hamilton, Montpelier, Munroe Falls, New Paris, Oakwood,Obetz, Phillipsburg, and West Alexandria have no minimum age. Geneva-on-the-Lakeuses 15 as a minimum age. Grand River, Rushsylvania, West Liberty and West Milton use16 as the minimum age. New Carlisle individuals 16 and 17 years old who earn $2, more are subject to the NAME AND ADDRESS CHANGES BELOWT axpayer NameName of spouse if joint returnAddressApt. # CityStateZip Social Security No. Move InMove Out/ / CCA DIVISION OF City Tax Form Due April 15, 2019 CCA FORM 120-16-IR Individual Joint Amended Extension Attached90% payment due January 15, 2019to avoid penalty and interest (see ordinance)() Attach Schedule E & K-1 Taxable Income Sourceor 1099s( Attach W -2s )NameName of spouse if joint returnCurrent addressApt.

5 # City, State, ZipPRINT OR TYPES ocial Security No. Move InMove Out//IF MOVED DURING THE YEAR SHOW CHANGES BELOW Move InMove Out//TAXABLE Employer's Expenses - Federal Tax Law defines eligible users( Line 2 less)Line 3( Schedule CAttach )(Attach Schedule E )CITY OF RESIDENCEPHONE NUMBER( ) IF TOTAL WAGES WERE EARNED IN THE SAME CITY YOU LIVED IN AND CITY TAX WAS CORRECTLY WITHHELD, COMPLETE ORANGE SECTIONS ONLY, SIGN, DATE, ATTACH W-2 Forms AND MAIL RETURN. ALL OTHERS SEE INSTRUCTIONS AND COMPLETE FORM IN ITS :PLACE CHECK, MONEY ORDER OR CREDIT CARD AUTHORIZATION ON TOP. PLACE Forms W-2 BELOW REMITTANCE. ATTACH ALL ITEMS DECLARE THAT I HAVE EXAMINED THIS RETURN AND ACCOMPANYING SCHEDULES AND STATEMENTS.

6 TO THE BEST OF MY KNOWLEDGE AND BELIEF IT IS TRUE, CORRECT AND COMPLETE. THE FIGURES USED HEREIN ARE THE SAME AS USED FOR FEDERAL Income TAX PURPOSES ADJUSTED TO Municipal Income TAX 9 Work CityCOLUMN 1 Work City NameList Each CityOnly OnceEmployment / Profit Tax 2018 LINECOLUMN 2 Taxable IncomeCOLUMN 3 WorkCity TaxRateCOLUMN 4 Tax DueCOLUMN 5 Less: TaxWithheld (Attach 2) OrW-Paid Other CitiesCOLUMN 6 Less: PriorYear CreditCOLUMN 7 Less: TaxPaid OnEmploymentTax EstimateCOLUMN 8 Tax Due CCA(If $ or less enter zero)10 Total each column. Add Positive Figures only in Column a negative figure is shown in Column 8, enter as credit or refund. The credit or refund amount must be greater than $ A-1 Employment / Profit Tax Estimate For 2019 (See instructions) must be completed to receive 2019 Estimated BillsCOLUMN 10 EstimatedTax DueCOLUMN 112018 Credit(From Col.)

7 8 only)COLUMN 12 Balance(Col. 10 Less Col. 11)COLUMN 13 Payment Due( of Col. 10 less Col. 11)1213 Total each BResidence Tax 2018 (Refer to Schedule R Worksheet on Reverse of Form Before Proceeding to Line 14)COLUMN 14 Residence CityCOLUMN 15 Taxable IncomeCOLUMN 16 Tax DueSchedule RCOLUMN 17 Less: ResidenceTax Withheld(Attach W-2)COLUMN 18 Less: PriorYear CreditCOLUMN 19 Less: Tax PaidOn ResidenceTax EstimateCOLUMN 20 Tax Due CCA(If $ or less enter zero)141516 Total each column. Add Positive Figures only in Column a negative figure is shown in Column 20, enter as credit or refund. The credit or refund amount must be greater than $ 21 Residence CitySECTION B-1 Residence Tax Estimate for 2019 (See instructions) must be completed to receive 2019 Estimated BillsCOLUMN 22 EstimatedResidence TaxCOLUMN 232018 Credit(From Line 16a only)COLUMN 24 Balance(Col.

8 22 Less Col. 23)COLUMN 25 Payment Due( of Col. 22 less Col. 23)17 Total each Due with this return Add Figures Shown in Last Column of Lines 10-13-15-17 Write Taxpayer Identification Number on Remittance. Make check payable to CCA - Division of of Preparer, if not TaxpayerDATESIGNHERES ignature of Spouse, if Joint ReturnDATES ignature of Taxpayer9Do you authorize your preparer to contact us regarding this return? YES@ NO@SECTION A Refund 11b14a16a16bCCA DIVISION OF TAXATIONCREDIT CARD AUTHORIZATIONDETACH HERE TO CHARGE YOUR Income TAX DUE YOU MUST COMPLETE THE FOLLOWING:Taxpayer s Social Security No. Taxpayer s nameCardholder s nameCardholder addresss Apt. # CityStateZip CHECK ONE VISADISCOVER MASTERCARD AMERICAN EXPRESS ACCOUNT NUMBEREXPIRATION DATEV CODEMO.

9 S AUTHORIZED SIGNATUREDATETOTAL AMOUNT CHARGED $ //NO Payment Enclosed - Mail to: CCA DIVISION OF TAXATIONPO BOX 94810 Cleveland OH 44101-4810 Payment Enclosed - Mail to: CCA DIVISION OF TAXATIONPO BOX 94723 Cleveland OH 44101-4723 Refund Request - Mail to: CCA DIVISION OF TAXATIONPO BOX 94520 Cleveland OH 44101-4520 MAILTOSCHEDULE LSchedule of Business and Rental LossesCityYear EndTaxable Income or LossAllowable Loss From Prior YearTotal Adjusted IncomeNote: Business and/or rental losses may be carried forward for five (5) years. A loss in one city may offset a business or rental gain in the same city. See Municipal ordinance for exceptions. Individuals with net profit/distributive share Income sourced in multiple municipalities with current and/or prior year losses refer to the CCA Resident Business/Rental Income RMUNICIPALITYADJUSTED RESIDENCE CITY PERCENTAGE RATES(FIND YOUR WORK CITY RATE IN THE SHADED AREA BELOW)NO (2018) (2019) Baltimore111111111111111111111 North Perry (Paulding County) R WORKSHEET INSTRUCTIONSDo not include Income reported on the CCA Resident Business/Rental Income 1 Enter name of your work city.

10 If more than one city, list each city separately. If work city is the same as residence city,enter name of work city on the ** : Income earned in same city you live in with employment tax withheld correctly is not subject to residence 2 Enter total Income earned in each city listed in Column 1. Add all figures and enter total on front of form on line 14, column 3 Enter name of residence city. If residence city changed during year, prorate Column 4 To locate your adjusted residence tax rate:(a) Find the WORK CITY RATE in the shaded area of SCHEDULE R.(b) Follow that WORK CITY column down until you reach the row naming your residence city.(c) Circle that percentage and enter in Column 5 Multiply Column 2 by Column 4 and enter the tax due. Add all figures and enter total on front of form on line 14, column R WORKSHEET - DO NOT INCLUDE Income REPORTED ON THE CCA RESIDENT BUSINESS / RENTAL Income WORKSHEETCOLUMN 1 WORK CITYCOLUMN 2 TAXABLE INCOMECOLUMN 3 RESIDENCE CITYCOLUMN 4 SCHEDULE R TAX RATEFROM ABOVECOLUMN 5 RESIDENCE TAX DUE COLUMN 2 TIMES COLUMN 4%%%**TOTALSE nter totals on tax returnLINE 14, COLUMN 15 LINE 14, COLUMN 16