us-oh/form/odt/ty2023/form-it-1040/document-1

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us-oh/form/odt/ty2023/form-it-1040/document-1 · Axiom

2023 Ohio IT 1040 Individual Income Tax Return Use only black ink/UPPERCASE letters. Use whole dollars only. Sequence No. 1 If deceased Single, head of household or qualifying surviving spouse Married filing jointly Married filing separately

State City ZIP code Ohio county (first four letters) Do not staple or paper clip.

1. Federal adjusted gross income (federal 1040 or 1040-SR, line 11). Place a "-" in the box if negative.......................................................................................................................................... .....1.

2a. Additions – Ohio Schedule of Adjustments, line 11 (include schedule).....................................................2a.

2b. Deductions – Ohio Schedule of Adjustments, line 44 (include schedule).................................................2b.

3. Ohio adjusted gross income (line 1 plus line 2a minus line 2b). Place a "-" in the box if negative... ....3. 4. Exemption amount (include Schedule of Dependents if applicable)............... ..............................4. Number of exemptions including you and your spouse/dependents, if applicable:

5. Ohio income tax base (line 3 minus line 4; if negative, enter zero)...............................................................5.

6. Taxable business income – Ohio Schedule of Business Income, line 15 (include schedule).....................6. 7. Taxable nonbusiness income (line 5 minus line 6; if negative, enter zero)....................................................7. Filing Status – Check one (as reported on federal income tax return)

AMENDED RETURN - Check here and include Ohio IT RE.

Address line 1 (number and street) or P.O. Box Primary taxpayer's SSN (required) Spouse’s SSN (if filing jointly) School district # Foreign country (if the mailing address is outside the U.S.) Foreign postal code First name Last name M.I. Spouse's first name (if filing jointly) Last name M.I. MM-DD-YY Residency Status – Check only one for primary Check only one for spouse (if filing jointly) Resident Part-year resident* Nonresident* Resident Part-year resident* *Indicate state Address line 2 (apartment number, suite number, etc.) Federal extension filers - check here. If someone can claim you (or your spouse if filing jointly) as a dependent, check here. Do not staple or paper clip. Ohio Nonresident Statement – See instructions for required criteria Primary meets the five criteria for irrebuttable presumption as nonresident. Spouse meets the five criteria for irrebuttable presumption as nonresident. NOL CARRYBACK - Check here and include Schedule IT NOL. If deceased 2023 IT 1040 – page 1 of 2 Spouse’s SSN *Indicate state Nonresident* 23000102 Do not write in this area; for department use only.

2023 Ohio IT 1040 Individual Income Tax Return Sequence No. 2 SSN: 2023 IT 1040 – page 2 of 2 If line 20 is MORE THAN line 13, skip to line 24. OTHERWISE, continue to line 21. Preparer's printed name Phone number

Primary signature Phone number Spouse’s signature Date  Sign Here (required): I have read this return. Under penalties of perjury, I declare that, to the best of my knowledge and belief, the return and all enclosures are true, correct and complete. If your refund is $1.00 or less, no refund will be issued. If you owe $1.00 or less, no payment is necessary. NO Payment Included – Mail to: Ohio Department of Taxation P.O. Box 2679 Columbus, OH 43270-2679 Payment Included – Mail to: Ohio Department of Taxation P.O. Box 2057 Columbus, OH 43270-2057  Authorize your preparer to discuss this return 7a. Amount from line 7 on page 1 .....................................................................................................................7a.

8a. Nonbusiness income tax liability on line 7a (see instructions for tax tables)...........................................................8a.

8b. Business income tax liability – Ohio Schedule of Business Income, line 16 (include schedule)...........................8b. 8c. Income tax liability before credits (line 8a plus line 8b)...........................................................................................8c. 9. Ohio nonrefundable credits – Ohio Schedule of Credits, line 38 (include schedule)..............................................9. 10. Tax liability after nonrefundable credits (line 8c minus line 9; if negative, enter zero).............................................10. 11. Interest penalty on underpayment of estimated tax (include Ohio IT/SD 2210)....................................................11. 12. Unpaid use tax (see instructions)............................................................................................................................12. 13. Total Ohio tax liability before withholding or estimated payments (add lines 10, 11 and 12)...............................13. 14. Ohio income tax withheld – Schedule of Ohio Withholding, part A, line 1 (include schedule and income statements)...............................................................................................................................................14. 15. Estimated and extension payments, and credit carryforward from last year's return..............................................15. 16. Refundable credits – Ohio Schedule of Credits, line 44 (include schedule)..........................................................16. 17. Amended return only – amount previously paid with original and/or amended return..........................................17. 18. Total Ohio tax payments (add lines 14, 15, 16 and 17)........................................................................................18. 19. Amended return only – overpayment previously requested on original and/or amended return..........................19. 20. Line 18 minus line 19. Place a "-" in the box if negative................................................................................. ......20.

21. Tax due (line 13 minus line 20). If line 20 is negative, ignore the "-" and add line 20 to line 13..............................21. 22. Interest due on late payment of tax (see instructions).............................................................................................................22.

23. TOTAL AMOUNT DUE (line 21 plus line 22). Include the Ohio Universal Payment Coupon (OUPC) and make check payable to “Ohio Treasurer of State”............................... AMOUNT DUE23. 24. Overpayment (line 20 minus line 13).......................................................................................................................24.

25. Original return only – portion of line 24 carried forward to next year’s tax liability..................................................25. 26. Original return only – portion of line 24 you wish to donate:

a. Wishes for Sick Children b. Wildlife Species c. Military Injury Relief

Total....26g.

d. Ohio History Fund e. Nature Preserves/Scenic Rivers f. Breast/Cervical Cancer 27. REFUND (line 24 minus lines 25 and 26g).............................................................................YOUR REFUND27. PTIN: Non-paid preparer P 23000202

2023 Ohio Schedule of Adjustments Use only black ink. Use whole dollars only. Sequence No. 3 Primary taxpayer’s SSN 1. Non-Ohio state or local government interest and dividends....................................................................................1. 2. Ohio pass-through entity taxes excluded from federal adjusted gross income........................................................2.

3. Taxes paid to another state or District of Columbia related to IRS notice 2020-75..................................................3. 4. 529 plan funds used for non-qualified expenses.....................................................................................................4. 5. Losses from sale or disposition of Ohio public obligations......................................................................................5.

6. Nonmedical withdrawals from a medical savings account.......................................................................................6.

7. Reimbursement of expenses previously deducted on an Ohio income tax return...................................................7. Federal 8. Internal Revenue Code 168(k) and 179 depreciation expense add-back................................................................8. 9. Exempt federal interest and dividends subject to state taxation..............................................................................9. 10. Federal conformity additions..................................................................................................................................10. 11. Total additions (add lines 1 through 10 ONLY). Enter here and on Ohio IT 1040, line 2a......................... 11.

12. Business income deduction – Ohio Schedule of Business Income, line 13...........................................................12.

13. Employee compensation earned in Ohio by residents of neighboring states..........................................................13. 14. Taxable refunds, credits, or offsets of state and local income taxes (federal 1040, Schedule 1, line 1)................14. 15. Taxable Social Security benefits (federal 1040 and 1040-SR, line 6b)..................................................................15.

16. Certain railroad benefits.........................................................................................................................................16. 17. Interest income from Ohio public obligations and purchase obligations; gains from the

disposition of Ohio public obligations; or income from a transfer agreement........................................................17. 18. Amounts contributed to an Ohio county's individual development account program.............................................18. 19. Amounts contributed to a STABLE account: Ohio's ABLE plan.............................................................................19.

20. Income earned in Ohio by a qualifying out-of-state business or employee for disaster work conducted during a disaster response period...............................................................................................20. 21. Certain payments related to the East Palestine train derailment...........................................................................21. 22. Ohio adoption grant program payments received from the Ohio Department of Job and Family Services...........22. Federal 23. Federal interest and dividends exempt from state taxation...................................................................................23. Additions (Only add the following amounts if they are not included on Ohio IT 1040, line 1) Deductions (Only deduct the following amounts if they are included on Ohio IT 1040, line 1) 2023 Schedule of Adjustments – page 1 of 2 23000302

2023 Ohio Schedule of Adjustments Sequence No. 4 Primary taxpayer’s SSN 24. Deduction of prior year 168(k) and 179 depreciation add-backs..........................................................................24.

25. Refund or reimbursements from the federal 1040, Schedule 1, line 8z for federal itemized deductions claimed on a prior year return...............................................................................................................................25.

26. Repayment of income reported in a prior year......................................................................................................26. 27. Wage expense not deducted based on the federal work opportunity tax credit....................................................27. 28. Federal conformity deductions................................................................................................................................28.

Uniformed Services 29. Military pay received by Ohio residents while stationed outside Ohio...................................................................29.

30. Compensation earned by nonresident military servicemembers and their civilian spouses...................................30. 31. Uniformed services retirement income.................................................................................................................31. 32. Military injury relief fund grants and veteran’s disability severance payments...........................................................32. 33. Certain Ohio National Guard reimbursements and benefits.................................................................................33.

Education 34. Amounts contributed to a 529 Plan.......................................................................................................................34.

35. Pell/Ohio College Opportunity taxable grant amounts used to pay room and board............................................35. 36. Ohio educator expenses in excess of federal deduction......................................................................................36. 37. Income attributable to loan repayments by the Ohio Department of Higher Education under the rural practice incentive program....................................................................................................................................37. 38. Grant program payments made by the Ohio Department of Higher Education on behalf of adopted students....38. Medical 39. Disability benefits..................................................................................................................................................39. 40. Survivor benefits...................................................................................................................................................40. 41. Unreimbursed medical and health care expenses (see instructions for worksheet; include a copy)..................41. 42. Medical savings account contributions/earnings (see instructions for worksheet; include a copy).....................42. 43. Qualified organ donor expenses...........................................................................................................................43. 44. Total deductions (add lines 12 through 43 ONLY). Enter here and on Ohio IT 1040, line 2b............................44. 2023 Schedule of Adjustments – page 2 of 2 23000402

2023 Ohio Schedule of Business Income Sequence No. 5 Enter all business income that you (and your spouse, if filing jointly) received during the tax year on this schedule. Enter only those amounts that are included in your federal adjusted gross income. Only one Schedule of Business Income should be used for each return filed. See R.C. 5747.01(B). Use whole dollars only. 2023 Schedule of Business Income – page 1 of 2 Part 1 – Business Income Note: Do not include amounts listed on the IRS schedules below that are nonbusiness income. See R.C. 5747.01(C). If the amount on a line is negative, place a “-“ in the box provided. 1. Schedule B – Interest and Ordinary Dividends.........................................................................................................1.

2. Schedule C – Net Profit or Loss From Business (Sole Proprietorship)....................................................... ....2.

3. Schedule D – Capital Gains and Losses.................................................................................................... ....3.

4. Schedule E – Supplemental Income and Loss........................................................................................... ....4. 5. Guaranteed payments or compensation from a pass-through entity to a 20% or greater direct

or indirect owner.......................................................................................................................................................5. 6. Schedule F – Net Profit or Loss From Farming.......................................................................................... ....6. 7. Add-back of electing pass-through entity taxes paid on the Ohio form IT 4738 that qualify as business income....7. 8. Add-back of taxes paid to another state or the District of Columbia related to IRS notice 2020-75 that

qualify as business income.......................................................................................................................................8. 9. Other business income or loss not reported above (e.g. form 4797 amounts)........................................... ....9. 10. Total business income (add lines 1 through 9)............................................................................................ ..10. Part 2 – Business Income Deduction 11. Enter the lesser of line 10 above or Ohio IT 1040, line 1. If negative, enter zero; stop here and do not complete Part 3....................................................................................................................11. 12. Enter $250,000 if filing status is single or married filing jointly; OR

Enter $125,000 if filing status is married filing separately.......................................................................................12. 13. Enter the lesser of line 11 or line 12. Enter here and on Ohio Schedule of Adjustments, line 12..................................13. Part 3 – Taxable Business Income Note: If Ohio IT 1040, line 5 is zero, do not complete Part 3.

14. Line 11 minus line 13...............................................................................................................................................14.

15. Taxable business income (enter the lesser of line 14 above or Ohio IT 1040, line 5). .Enter here and

on Ohio IT 1040, line 6............................................................................................................................................15.

16. Business income tax liability – multiply line 15 by 3% (.03). Enter here and on Ohio IT 1040, line 8b......................16. 23260102 Do not write in this area; for department use only. . Use only black ink/UPPERCASE letters. Primary taxpayer’s SSN

2023 Ohio Schedule of Business Income Sequence No. 6 Part 4 – Business Sources List all sources of business income, with Ohio sources listed first. Also separately list your ownership percentage and/or your spouse’s ownership percent age (if filing jointly). If necessary, complete additional copies of this page and include with your return. Spouse’s ownership FEIN / SSN Primary ownership Business name Primary taxpayer’s SSN 2023 Schedule of Business Income – page 2 of 2 1.

8. Spouse’s ownership FEIN / SSN Primary ownership Business name Spouse’s ownership FEIN / SSN Primary ownership Business name Spouse’s ownership FEIN / SSN Primary ownership Business name Spouse’s ownership FEIN / SSN Primary ownership Business name Spouse’s ownership FEIN / SSN Primary ownership Business name Spouse’s ownership FEIN / SSN Primary ownership Business name Spouse’s ownership FEIN / SSN Primary ownership Business name % % % % % % % % % % % % % % % % . . . . . . . . . . . . . . . . 23260202

2023 Ohio Schedule of Credits Use only black ink. Use whole dollars only. 2023 Schedule of Credits – page 1 of 2

1. Tax liability before credits (from Ohio IT 1040, line 8c).............................................................................................1.

2. Retirement income credit (include 1099-R forms)..................................................................................................2.

3. Lump sum retirement credit (include a copy of the worksheet and 1099-R forms)...........................................3.

4. Senior citizen credit (must be 65 or older to claim this credit)................................................................................4.

5. Lump sum distribution credit (include a copy of the worksheet and 1099-R forms).........................................5.

6. Child care & dependent care credit (include a copy of the worksheet)..............................................................6.

7. Displaced worker training credit (include a copy of the worksheet and all required documentation)................7.

8. Campaign contribution credit for Ohio statewide office or General Assembly........................................................8.

9. Exemption credit.....................................................................................................................................................9.

10. Total (add lines 2 through 9).................................................................................................................................10. 11. Tax less credits (line 1 minus line 10; if negative, enter zero).............................................................................. 11.

12. Joint filing credit (see instructions for table). % times line 11, up to $650...............................................................12. 13. Earned income credit............................................................................................................................................13. 14. Home school expenses credit (include copies of all required documentation)..............................................14. 15. Scholarship donation credit (include copies of all required documentation)..................................................15. 16. Nonchartered, nonpublic school tuition credit (include copies of all required documentation).......................16. 17. Credit for work-based learning experiences (include a copy of the credit certificate).....................................17. 18. Ohio adoption credit carryforward........................................................................................................................18. 19. Nonrefundable job retention credit (include a copy of the credit certificate)...................................................19. 20. Credit for eligible new employees in an enterprise zone (include a copy of the credit certificate)..................20. 21. Credit for the beginning farmers financial management program (include a copy of the credit certificate)....21. 22. Welcome Home Ohio credit (include a copy of the credit certificate)..............................................................22. 23. Credit for sale/rental of agricultural assets to beginning farmers (include a copy of the credit certificate).....23.

Primary taxpayer’s SSN Many of these credits must be calculated using a worksheet and/or be supported by additional required documentation. See the instructions for worksheets and information on supporting documentation. Nonrefundable Credits Sequence No. 7 Do not write in this area; for department use only. 23280102

2023 Ohio Schedule of Credits 2023 Schedule of Credits – page 2 of 2 24. Grape production credit........................................................................................................................................24. 25. InvestOhio credit (include a copy of the credit certificate)...............................................................................25. 26. Lead abatement credit (include a copy of the credit certificate)......................................................................26. 27. Opportunity zone investment credit (include a copy of the credit certificate)..................................................27.

28. Technology investment credit carryforward (include a copy of the credit certificate)......................................28. 29. Enterprise zone day care & training credits (include a copy of the credit certificate)......................................29. 30. Research & development credit (include a copy of the credit certificate).......................................................30. 31. Nonrefundable Ohio historic preservation credit (include a copy of the credit certificate)..............................31. 32. Ohio low-income housing credit (include a copy of the credit certificate).......................................................32. 33. Affordable single-family housing credit (include a copy of the credit certificate).............................................33. 34. Total (add lines 12 through 33).............................................................................................................................34. 35. Tax less additional credits (line 11 minus line 34; if negative, enter zero)............................................................35. 36. Nonresident credit – Ohio IT NRC, line 20 (include a copy)...............................................................................36.

37. Resident credit – Ohio IT RC, line 7 (include a copy).........................................................................................37. 38. Total nonrefundable credits (add lines 10, 34, 36 and 37; enter here and on Ohio IT 1040, line 9).................38. 39. Refundable Ohio historic preservation credit (include a copy of the credit certificate)....................................39.

40. Refundable job creation credit & job retention credit (include a copy of the credit certificate).................................40. 41. Pass-through entity credit (include a copy of all Ohio IT K-1s).........................................................................41. 42. Motion picture & Broadway theatrical production credit (include a copy of the credit certificate)...................42.

43. Venture capital credit (include a copy of the credit certificate)........................................................................43.

44. Total refundable credits (add lines 39 through 43; enter here and on Ohio IT 1040, line 16)...........................44. Primary taxpayer’s SSN Sequence No. 8 Residency Credits Refundable Credits 23280202

Dependent's date of birth (MM-DD-YYYY) Do not list the primary filer and/or spouse (if filing jointly) as dependents on this schedule. Use this schedule to claim dependents. If you have more than 15 dependents, complete additional copies of this schedule and include them with your income tax return. Abbreviate the “Dependent’s relationship to you” if necessary. 1. 2. 3. 4. 5. 6. 7. Dependent’s SSN Dependent’s first name Dependent's last name M.I. Dependent’s relationship to you Dependent's date of birth (MM-DD-YYYY) Dependent's last name Dependent’s SSN Dependent’s first name M.I. Dependent’s relationship to you Dependent's date of birth (MM-DD-YYYY) Dependent’s SSN Dependent’s first name Dependent's last name M.I. Dependent’s relationship to you Dependent's date of birth (MM-DD-YYYY) Dependent's last name Dependent’s SSN Dependent’s first name M.I. Dependent’s relationship to you Dependent's date of birth (MM-DD-YYYY) Dependent's last name Dependent’s SSN Dependent’s first name M.I. Dependent’s relationship to you Dependent's date of birth (MM-DD-YYYY) Dependent’s SSN Dependent’s first name Dependent's last name M.I. Dependent’s relationship to you Dependent's date of birth (MM-DD-YYYY) Dependent's last name Dependent’s SSN Dependent’s first name M.I. Dependent’s relationship to you 2023 Schedule of Dependents – page 1 of 2 Primary taxpayer's SSN Sequence No. 9 2023 Ohio Schedule of Dependents Use only black ink/UPPERCASE letters. 23230102 Do not write in this area; for department use only. - - - - - - - - - - - - - -

8. 9. 10. 11. 12. 13. 14. 15. Dependent's date of birth (MM-DD-YYYY) Dependent’s SSN Dependent’s first name Dependent's last name M.I. Dependent’s relationship to you Dependent's date of birth (MM-DD-YYYY) Dependent's last name Dependent’s SSN Dependent’s first name M.I. Dependent’s relationship to you Dependent's date of birth (MM-DD-YYYY) Dependent’s SSN Dependent’s first name Dependent's last name M.I. Dependent’s relationship to you Dependent's date of birth (MM-DD-YYYY) Dependent's last name Dependent’s SSN Dependent’s first name M.I. Dependent’s relationship to you Dependent's date of birth (MM-DD-YYYY) Dependent's last name Dependent’s SSN Dependent’s first name M.I. Dependent’s relationship to you Dependent's date of birth (MM-DD-YYYY) Dependent’s SSN Dependent’s first name Dependent's last name M.I. Dependent’s relationship to you Dependent's date of birth (MM-DD-YYYY) Dependent's last name Dependent’s SSN Dependent’s first name M.I. Dependent’s relationship to you Dependent's date of birth (MM-DD-YYYY) Dependent's last name Dependent’s SSN Dependent’s first name M.I. Dependent’s relationship to you Primary taxpayer's SSN 2023 Schedule of Dependents – page 2 of 2 Sequence No. 10 2023 Ohio Schedule of Dependents 23230202 - - - - - - - - - - - - - - - -

Part A - Total Withholding 1. Total of all Ohio state tax withheld on pages 1 and 2 as well as any additional pages. Enter here

and on line 14 of your Ohio IT 1040...............................................................................................................1. Box 2 - Federal income tax withheld Box 1 - Wages, tips, other compensation P/S Box b - EIN Box 15 - Employer’s Ohio ID number 2023 Schedule of Withholding – page 1 of 2 List your and your spouse’s (if filing jointly) income statements only if they have Ohio withholding. In the “P/S” box, if the income statement belongs to the primary taxpayer, enter “P”; if the income statement belongs to the spouse, enter “S”. If the Ohio ID number on a statement has 9 digits, enter only the first 8 digits. Complete additional copies of this schedule if necessary. Include state copies of your income statements. Box 16 - Ohio wages, tips, etc. Box 17 - Ohio income tax Part B - W-2s Box 2 - Federal income tax withheld Box 1 - Wages, tips, other compensation P/S Box b - EIN Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc. Box 17 - Ohio income tax Box 2 - Federal income tax withheld Box 1 - Wages, tips, other compensation P/S Box b - EIN Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc. Box 17 - Ohio income tax Box 2 - Federal income tax withheld Box 1 - Wages, tips, other compensation P/S Box b - EIN Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc. Box 17 - Ohio income tax Box 2 - Federal income tax withheld Box 1 - Wages, tips, other compensation P/S Box b - EIN Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc. Box 17 - Ohio income tax Box 2 - Federal income tax withheld Box 1 - Wages, tips, other compensation P/S Box b - EIN Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc. Box 17 - Ohio income tax Box 2 - Federal income tax withheld Box 1 - Wages, tips, other compensation P/S Box b - EIN Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc. Box 17 - Ohio income tax Sequence No. 11 1.

2023 Schedule of Ohio Withholding Primary taxpayer’s SSN Use only black ink/UPPERCASE letters. Use whole dollars only. 23350102

Total distribution Box 1 - Gross distribution P/S Payer’s TIN Box 15 - Payer’s Ohio number Box 4 - Federal income tax withheld Box 14 - Ohio tax withheld Part C - 1099-Rs Box 4 - Federal income tax withheld Box 1 - Reportable winnings P/S Payer’s federal ID number Box 13 - Ohio state ID number Box 14 - Ohio state winnings Box 15 - Ohio income tax withheld Box 4 - Federal income tax withheld Box 1 - Nonemployee compensation P/S Payer’s TIN Box 6 - Payer’s Ohio number Box 7 - State income Box 5 - Ohio tax withheld Box 4 - Federal income tax withheld Box 1 - Nonemployee compensation P/S Payer’s TIN Box 6 - Payer’s Ohio number Box 7 - State income Box 5 - Ohio tax withheld Box 7 - Distribution code Total distribution Box 1 - Gross distribution P/S Payer’s TIN Box 15 - Payer’s Ohio number Box 4 - Federal income tax withheld Box 14 - Ohio tax withheld Box 7 - Distribution code Total distribution Box 1 - Gross distribution P/S Payer’s TIN Box 15 - Payer’s Ohio number Box 4 - Federal income tax withheld Box 14 - Ohio tax withheld Box 7 - Distribution code Total distribution Box 1 - Gross distribution P/S Payer’s TIN Box 15 - Payer’s Ohio number Box 4 - Federal income tax withheld Box 14 - Ohio tax withheld Box 7 - Distribution code Part D - W-2Gs Box 4 - Federal income tax withheld Box 1 - Reportable winnings P/S Payer’s federal ID number Box 13 - Ohio state ID number Box 14 - Ohio state winnings Box 15 - Ohio income tax withheld Box 4 - Federal income tax withheld Box 1 - Reportable winnings P/S Payer’s federal ID number Box 13 - Ohio state ID number Box 14 - Ohio state winnings Box 15 - Ohio income tax withheld Part E - 1099-NECs 2023 Schedule of Withholding – page 2 of 2 Sequence No. 12 1.

1. 2. 2023 Schedule of Ohio Withholding Primary taxpayer’s SSN 23350202

Federal Privacy Act Notice Because we require you to provide us with a Social Security number, the Federal Privacy Act of 1974 requires us to inform you that providing us with your Social Security number is mandatory. Ohio Revised Code sections 5703.05, 5703.057 and 5747.08 authorize us to request this information. We need your Social Security number in order to administer this tax. Cut on the dotted lines. Use only black ink.  0 0 , ,  Taxpayer’s SSN Amount of Payment Using UPPERCASE letters, print the first three letters of the taxpayer’s last name. Tax Year ID Type Coupon Type Ohio Universal Payment Coupon (OUPC) $ Note: Pay online at tax.ohio.gov/pay 440 01 54 Individual Income Tax Make payment payable to: Ohio Treasurer of State Mail to: Ohio Department of Taxation, P.O. Box 182131, Columbus, OH 43218-2131 First name M.I. Last name Address City, State, ZIP code 222 2023 Ohio Universal Payment Coupon (IT) Include the coupon below with your Ohio individual income tax payment. Important • Make payment payable to: Ohio Treasurer of State • Include the tax year, “IT 1040”, and the last four digits of your SSN on the “Memo” line of your payment. • Do not send cash. • Do not use this coupon to make a payment for a school district income tax return. Electronic Payment Options You can make your payment electronically even if you file by paper. To pay by electronic check, credit card, or debit card, visit tax.ohio.gov/pay OR scan with your phone.