CCA-MUNICIPAL INCOME TAX P.O. BOX 94520 CLEVELAND, OHIO 44101-4520
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VISA / MASTERCARD / DISCOVER PAYMENT AUTHORIZATION
DETACH HERE
TO CHARGE YOUR INCOME TAX DUE TO YOUR VISA, MASTERCARD OR DISCOVER YOU MUST COMPLETE THE FOLLOWING: (CHECK ONE) VISA MASTERCARD DISCOVER
ACCOUNT NUMBER TAXPAYER NAME EXPIRATION DATE MO. AUTHORIZED SIGNATURE DATE YR.
TOTAL AMOUNT CHARGED VISA / MASTERCARD / DISCOVER
2004
SOCIAL SECURITY NO.
2004-City Tax Form — Due April 15, 2005
CCA-MUNICIPAL INCOME TAX P.O. BOX 94520 CLEVELAND, OHIO 44101-4520 Phone: (216) 664-2070, Toll Free 1-800-223-6317
http://www.ccatax.ci.cleveland.oh.us
80% payment due January 31, 2005 to avoid Penalty and Interest
EST. TAX
PAID AS OF 11/30/04
CREDIT
4th QUARTER
Individual
1. Employer’s Name a. b. c. d.
Joint
CITY
Extension Attached
INCOME
CCA FORM 120-16-IR
Social Security No.
TAXABLE INCOME
Name Name of spouse if joint return
PRINT OR TYPE
Current address City, State and Zip
Apt #
Move In Move Out
IF MOVED DURING THE YEAR, SHOW OLD ADDRESS BELOW
2. Total Wages ( Attach W-2’s) or 1099’s 3. Less Allowable Attach Fed. 2106 2106 Expenses ( & Schedule A ) 4. Net Taxable Wages ( Line 2 less ) Line 3
Attach 5. Business Income( Schedule C ) Attach ( Schedule E ) Attach 7. K-1 Income (Schedule E & K-1)
6. Rental Income
Move In Move Out
8. Other Income Source CITY OF RESIDENCE PHONE NUMBER
PLACE CHECK, MONEY ORDER OR VISA / MASTERCARD / DISCOVER AUTHORIZATION ON TOP. PLACE FORMS W-2 BELOW REMITTANCE. ATTACH ALL ITEMS HERE.
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)
NOTE: IF TOTAL WAGES WERE EARNED IN THE SAME CITY YOU LIVED IN AND CITY TAX WAS CORRECTLY WITHHELD, COMPLETE RED SECTIONS ONLY, SIGN FORM AT BOTTOM AND ATTACH W-2 FORMS, ALL OTHERS SEE INSTRUCTIONS AND COMPLETE FORM IN ITS ENTIRETY.
SECTION A
L For Office I Use N Only E
Employment / Profit Tax 2004
COLUMN 1 Work City Name List Each City Only Once COLUMN 2 COLUMN 3 Work City Tax Rate COLUMN 4 COLUMN 5 Less: Tax Withheld Or Paid Other Cities COLUMN 6 COLUMN 7 Less: Tax Paid On Employment Tax Estimate COLUMN 8
Taxable Income
Tax Due
Less: Prior Year Credit
Tax Due CCA
9 (MS 368011) Face 05 Black (10% screen)
10 11
For Office Use Only
Total each column. Add Positive Figures only in Column 8. If a negative figure is shown in Column 8, enter as credit or refund.
CREDIT
REFUND
A
Enter amount to be credited to 2005 here and in Column 11
B
COLUMN 10 Estimated Tax Due
Enter amount to be refunded here
SECTION A-1
Employment / Profit Tax Estimate For 2005 (See Instructions) - must be completed to receive 2005 Estimated Bills
COLUMN 9 Work City COLUMN 11 2004 Credit (From Col. 8 only) COLUMN 12 Balance (Col. 10 Less Col. 11) COLUMN 13 Payment Due ( 1⁄4 of Col. 10 Less Col. 11)
12
13 Total Each Column
185 Red(20% screen) 11-16-04
SECTION B
For Office Use Only
Residence Tax 2004 (Refer to Schedule R Worksheet on Reverse of Form Before Proceeding to Line 14)
COLUMN 14 Residence City COLUMN 15 Taxable Income COLUMN 16 Tax Due Schedule R COLUMN 17 Less: Residence Tax Withheld (Attach W-2) COLUMN 18 Less: Prior Year Credit COLUMN 19 Less: Tax Paid On Residence Tax Estimate COLUMN 20 Tax Due CCA
14
15 16
For Office Use Only
Total each column. Add Positive Figures only in Column 20. If a negative figure is shown in Column 20, enter as credit or refund.
CREDIT
REFUND
A
Enter amount to be credited to 2005 here and in Column 23
B
COLUMN 22 Estimated Residence Tax
Enter amount to be refunded here
SECTION B-1
Residence Tax Estimate for 2005 (Refer to Schedule R Worksheet on Reverse of Form) - must be completed to receive 2005 Estimated Bills
COLUMN 21 Residence City COLUMN 23 2004 Credit (From Col. 20 only) COLUMN 24 Balance (Col. 22 Less Col. 23) COLUMN 25 Payment Due (1⁄4 of Col. 22 Less Col. 23)
17 Total Each Column 18
SIGN HERE
Tax Due with this return - Add Figures Shown in Last Column of Lines 10-13-15-17 Write Social Security Number on Remittance
Signature of Taxpayer Signature of Spouse, if Joint Return
I DECLARE THAT I HAVE EXAMINED THIS RETURN AND ACCOMPANYING SCHEDULES AND STATEMENTS. TO THE BEST OF MY KNOWLEDGE AND BELIEF THEY ARE TRUE, CORRECT, AND COMPLETE. THE FIGURES USED HEREIN ARE THE SAME AS USED FOR FEDERAL INCOME TAX PURPOSES ADJUSTED TO MUNICIPAL INCOME TAX ORDINANCES.
DATE
Signature of Preparer, If not Taxpayer
DATE
(Make check payable to Central Collection Agency)
Section A
WORK CITY
Ada Akron Andover Ashtabula Aurora Avon Avon Lake Barberton Bay Village Beachwood Bedford Bedford Heights Berea Bowling Green Bratenahl Brecksville Broadview Heights Brooklyn Brooklyn Heights Brook Park Brunswick Burton Canton Chagrin Falls Chardon** Cleveland
2004 WORK CITY TAX RATES
TAX OFFICE RATE CODE WORK CITY
2% 2% 1% .75% 2% 2% 1.3% 1% 2% 2% 1.75% 2.85% 2% 1.5% 1% 2% 1% 1.5% 1% 1% 2% 1.5% 2.5% 1% 2% 1% 210 235 238 239 240 250 253 266 270 273 277 280 295 300 311 320 330 345 347 356 357 370 371 378 390 391 Kent Kirtland Lakewood Liberty Center Lima Linndale Lorain Lordstown Lyndhurst Macedonia Madison Village Mansfield Maple Heights Maumee Mayfield Heights Mayfield Village Medina Mentor Mentor-on-the-Lake Metamora Middleburg Heights Middlefield Newburgh Heights Northfield Village** North Baltimore North Olmsted
CCA MEMBER COMMUNITIES
TAX OFFICE RATE CODE
1% 2.5% 1% 1% 2% 1% 1.5% 2% 1% 1% 2% 2% 2% .5% 1% 1% 1% 1% 1.8% 2% 2% 1.5% 1% 1.5% 2% 1% 555 560 565 570 580 585 590 600 603 605 610 620 630 640 645 650 655 657 660 665 670 675 698 700 720 722
(LOCATE YOUR WORK CITY AND ITS TAX RATE) 2005 Tax Rate Change - * 3%, **2%,***1%
TAX OFFICE RATE CODE WORK CITY
2% 2% 1.5% 1% 1.5% 2% 1.75% .5% 1.5% 2% 1% 1.75% 2% 1.5% 1% 1.5% 1.25% 2% 2% 1% 1.75% 1% 2% 2% 1% 2% 392 394 400 408 410 420 435 437 440 450 455 456 460 465 480 485 487 490 495 497 500 510 540 545 548 550 North Perry Village North Randall North Ridgeville North Royalton Oakwood Village Village of Oakwood Olmsted Falls Orange Orrville Orwell Painesville Parma Parma Heights* Paulding Peninsula Pepper Pike Perry Perrysville Ravenna Richfield Richmond Heights Rittman Rock Creek Rocky River Seven Hills Seville
TAX OFFICE RATE CODE WORK CITY
1.15% 2.25% 1.5% 1.8% 2% 1.5% 1.5% 2% 1.5% 1.5% 2.25% 2% 2% 1.92% 1.5% 2% 2% 2% 2% 2% 1.35% 1% 2% 1.5% 1% 2% 002 005 006 012 010 020 022 025 040 050 060 070 100 114 120 130 140 150 160 170 175 176 178 180 185 200 Cleveland Heights Columbus Creston Cridersville*** Cuyahoga Falls Cuyahoga Heights Defiance Dunkirk East Cleveland Eastlake Elyria Euclid Fairport Harbor Fairview Park Findlay Garfield Heights Gates Mills Geneva Geneva-on-the-lake Grand Rapids Grand River Highland Heights Highland Hills Hudson Independence Jefferson
WORK CITY
Shaker Heights Sheffield Lake Sheffield Village Solon South Euclid South Russell Stow Streetsboro Strongsville Timberlake Toledo Twinsburg University Heights Valleyview Wadsworth Walton Hills Warrensville Heights Westfield Center Westlake Wickliffe Willoughby Willoughby Hills Willowick Woodmere Wooster Youngstown
TAX RATE
1.75% 1.25% 1.5% 2% 1.5% 1% 2% 1% 2% 1% 2.25% 2% 1.5% 2% 1.3% 2% 2% 1% 1.5% 2% 2% 1.5% 2% 2% 1% 2.75%
OFFICE CODE
750 753 752 760 770 772 773 775 780 788 791 795 800 810 815 820 830 838 840 860 870 880 890 900 910 950
Section B
CCA RESIDENCE CITY Rates apply to 2004 unless indicated otherwise Ada Andover Barberton Bratenahl Burton Chardon (2004) Chardon (2005) Cleveland Creston Cridersville (2004) Cridersville (2005) Dunkirk Euclid Gates Mills Geneva-on-the-Lake Grand Rapids Grand River Highland Hills Liberty Center Linndale Madison Village Medina Mentor Mentor-on-the-Lake Metamora Middlefield (2004) Middlefield (2005) Northfield Village (2004) Northfield Village (2005) North Baltimore North Perry Village North Randall Village of Oakwood Orwell Painesville Paulding Peninsula Perry Rock Creek Rocky River Seville South Russell Timberlake Wadsworth Warrensville Heights Willoughby Willoughby Hills
2004 SCHEDULE R ▲
Section A Tax payments, credits and refunds only apply to CCA member communities.
WORK CITY WORK CITY WORK CITY WORK CITY WORK CITY WORK CITY WORK CITY WORK CITY WORK CITY WORK CITY NO TAX .5% 1% 1.3% 1.5% 1.75% 2% 2.25% 2.85% 2.5% WITHHELD
1.15 1.5 2 1.5 1 1 2 2 1 .75 1 1 2.85 1 1 1 2 2.5 1 2 1 1.25 2 2 1 1 1 1.5 2 1 1 2.5 1 1 2 .50 1 1 1 1.5 1 1 1 1.3 2 2 1.5 .65 1 1.5 1.25 .75 1 1.75 1.75 1 .63 .88 .50 2.35 .75 .75 .75 1.5 2 .50 1.5 1 1.06 1.5 1.5 .75 .50 1 1 1.5 .50 .50 2 .50 .50 1.5 .50 .75 .50 .75 1 .88 .63 .75 .80 1.75 1.5 1 .15 .50 1 1 .50 1 1.5 1.5 1 .56 .75 0 1.85 .50 .50 .50 1 1.5 0 1 1 1.06 1 1 .50 0 1 .50 1 0 0 1.5 0 0 1 .50 .50 0 .50 .50 .75 .25 .50 .30 1.5 1 .50 0 0 .70 .85 .50 1 1.35 1.35 1 .56 .75 0 1.55 .50 .50 .50 .70 1.2 0 .70 1 1.06 .70 .70 .50 0 1 .20 .70 0 0 1.20 0 0 .70 .50 .50 0 .50 .50 .75 .25 .50 .30 1.35 .70 .50 0 0 .50 .75 .50 1 1.25 1.25 1 .56 .75 0 1.35 .50 .50 .50 .50 1 0 .50 1 1.06 .50 .50 .50 0 1 0 .50 0 0 1 0 0 .50 .50 .50 0 .50 .50 .75 .25 .50 .30 1.25 .50 .50 0 0 .25 .75 .50 1 1.13 1.13 1 .56 .75 0 1.10 .50 .50 .50 .25 .75 0 .25 1 1.06 .25 .25 .50 0 1 0 .25 0 0 .75 0 0 .25 .50 .50 0 .50 .50 .75 .25 .50 .30 1.13 .25 .50 0 0 0 .75 .50 1 1 1 1 .56 .75 0 .85 .50 .50 .50 0 .50 0 0 1 1.06 0 0 .50 0 1 0 0 0 0 .50 0 0 0 .50 .50 0 .50 .50 .75 .25 .50 .30 1 0 .50 0 0 0 .75 .50 1 1 1 1 .56 .75 0 .60 .50 .50 .50 0 .25 0 0 1 1.06 0 0 .50 0 1 0 0 0 0 .25 0 0 0 .50 .50 0 .50 .50 .75 .25 .50 .30 1 0 .50 0 0 0 .75 .50 1 1 1 1 .56 .75 0 .35 .50 .50 .50 0 0 0 0 1 1.06 0 0 .50 0 1 0 0 0 0 0 0 0 0 .50 .50 0 .50 .50 .75 .25 .50 .30 1 0 .50 0 0 0 .75 .50 1 1 1 1 .56 .75 0 0 .50 .50 .50 0 0 0 0 1 1.06 0 0 .50 0 1 0 0 0 0 0 0 0 0 .50 .50 0 .50 .50 .75 .25 .50 .30 1 0 .50
2004 SCHEDULE R ADJUSTED RESIDENCE CITY PERCENTAGE RATES (FIND YOUR WORK CITY RATE IN THE SHADED AREA BELOW)
INSTRUCTIONS Schedule R Worksheet
Section B
Column 1 Enter name of your work city. If more than one city, list each city separately. If work city is the same as residence city, enter name of work city on line**. Column 2 Enter total income earned in each city listed in Column 1. Column 3 Enter name of residence city. If residence city changed during 2004, prorate Column 2 accordingly. Column 4 Locating your adjusted residence tax rate. (a) Find your work city tax rate in WORK CITY TAX RATES SCHEDULE. (b) Find the same WORK CITY RATE in the shaded area of 2004. (c) Follow that WORK CITY column down until you reach the line naming your residence city. (d) Circle that percentage and enter in Column 4. Column 5 Multiply Column 2 by Column 4 and enter the tax due your residence city.
SCHEDULE R WORKSHEET
COLUMN 1 WORK CITY COLUMN 2 TAXABLE INCOME COLUMN 3 RESIDENCE CITY
COLUMN 4 SCHEDULE R TAX RATE FROM ABOVE
COLUMN 5 RESIDENCE TAX DUE COLUMN 2 TIMES COLUMN 4
* * NOTE:
Income earned in same city you live in with employment tax withheld correctly is not subject to residence tax.
% % % ** TOTALS Enter totals on tax return
* * * If your work is not listed in Section A, you
LINE 14, COLUMN 16
LINE 14, COLUMN 15
can find the work city tax rate by dividing city tax withheld by taxable wages as shown on your W-2 form.
2004
Form 120-16-EC
CCA-MUNICIPAL INCOME TAX P.O. BOX 94520 CLEVELAND, OHIO 44101-4520 PHONE: (216) 664-2070, Toll Free 1-800-223-6317
EXEMPTION CERTIFICATE
Name Name of spouse if joint return Current address City, State and Zip Apt # Social Security No.
MOVE IN MOVE OUT
If moved during the year, show old address above.
I AM REQUIRED TO FILE THIS FORM SINCE I LIVE IN A MANDATORY FILING CITY. I AM NOT REQUIRED TO PAY CITY INCOME TAX BECAUSE:
1. 2. RETIRED, received only pension, Social Security, Interest or Dividend Income. 4. AN ACTIVE MEMBER OF THE ARMED FORCES OF THE UNITED STATES FOR THE ENTIRE YEAR 2004. (This does not include civilians employed by the 5. military or National Guard.) 3. UNDER 18 FOR THE ENTIRE YEAR 2004. *(Residents of Creston, Grand River, Medina, Middlefield and Painesville see instructions on reverse.) SIGNATURE OF TAXPAYER SIGNATURE OF SPOUSE, IF JOINT RETURN NO EARNED INCOME FOR THE ENTIRE YEAR 2004. (Welfare, Unemployment, SSI, etc.) BUSINESS CLOSED OR RENTAL PROPERTY SOLD / / (date) DATE
PHONE NUMBER
STOP -- If you have qualified and completed the Exemption Certificate,
detach here ▼ and return in the envelope provided.