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Depa~ment of 2015 Universal IT 1040
* Ohio I Taxation
Rev. 11/15
Individual Income Tax Return 1111111111 1111111 1111111 *

Note: For taxable year 2015 and forward, this form encompasses the IT 1040, IT 1040EZ and amended IT 1040X.

Are you ﬁ ling this as an amended return? Yes No If yes, attach Ohio IT RE, 2015 Reason and Explanation of Corrections
Is this a Net Operating Loss (NOL) carryback? Yes No If yes, attach Schedule IT NOL
Taxpayer Social Security no. (required)  If deceased Spouse’s Social Security no. (if ﬁling jointly)  If deceased Enter school district # for
this return (see instructions).
check box check box SD# 
First name M.I. Last name

Spouse's ﬁ rst name (only if married ﬁling jointly) M.I. Last name

Mailing address (for faster processing, use a street address)

City State ZIP code Ohio county (ﬁ rst four letters)

Home address (if different from mailing address) – do NOT show city or state ZIP code Ohio county (ﬁ rst four letters)

Foreign country (if the mailing address is outside the U.S.) Foreign postal code

Ohio Residency Status – Check applicable box Filing Status – Check one (as reported on federal income tax return,
Full-year Part-year Nonresident with limited exceptions – see instructions)
resident resident Indicate state
Single, head of household or qualifying widow(er)
Check applicable box for spouse (only if married ﬁling jointly)
Full-year Part-year Nonresident Married ﬁling jointly Married ﬁling separately
Yes No
resident resident Indicate state 
Yes No Did you ﬁ le federal extension form 4868? ....................................
Ohio Political Party Fund Yes No
Do you want $1 to go to this fund?............................................ Is someone else claiming you or your spouse (if joint return) as
a dependent? If yes, enter "0" on line 4........................................
If joint return, does your spouse want $1 to go to this fund?.....
Note: Checking “Yes” will not increase your tax or decrease your refund.
If the amount on a line is negative, place a negative sign ("–") in the box provided.
1. Federal adjusted gross income (from IRS forms 1040, line 37; 1040A, line 21;
1040EZ, line 4; 1040NR, line 36; or 1040NR-EZ, line 10)................................................................. 1. . 00

00
2a. Additions to federal adjusted gross income (attach Ohio Schedule A, line 11) ........................... 2a. .

2b. Deductions from federal adjusted gross income (attach Ohio Schedule A, line 35).................... 2b. . 00

3. Ohio adjusted gross income (line 1 plus line 2a minus line 2b) .................................................... 3. . 00
00
4. Personal and dependent exemption deduction (if claiming dependent(s), attach Schedule J)..... 4. .

5. Ohio income tax base (line 3 minus line 4; if less than -0-, enter -0-) ........................................... 5. . 00

6. Taxable business income (attach Ohio Schedule IT BUS, line 13) ............................................... 6. .00
7. Line 5 minus line 6 (if less than -0-, enter -0-)...............................................................................7. .00
Enclose your federal income tax return
if line 1 of this return is -0- or negative.
Do not write in this area; for department use only.
/ /
Postmark date Code

2015 Universal IT 1040 – page 1 of 2

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                        Depa~ment of                      2015 Universal IT 1040 
*     Ohio I Taxation 
                        Rev. 11/15                  Individual Income Tax Return 
                                                                                                                                                               1111111111 11111111111111       *  
                                                                                                                                                                        
  SSN 

  7a. Amount from line 7 on page 1 .....................................................................................................7a.                                                .00 
 
                                                                                                                                                                                           00 
  8a. Tax liability on line 7a (see instructions for tax tables) .............................................................................8a.                                          . 
                                                                                                                                                                                           00 
  8b. Business income tax liability (attach Ohio Schedule IT BUS, line 14) ..................................................... 8b.                                                       . 
                                                                                                                                                                                           00 
  8c. Tax liability before credits (line 8a plus line 8b) ....................................................................................... 8c.                                      . 
                                                                                                                                                                                           00 
  9. Ohio nonrefundable credits/grants (attach Ohio Schedule of Credits, line 35) ......................................... 9.                                                             . 
                                                                                                                                                                                           00 
  10. Tax liability after nonrefundable credits/grants (line 8c minus line 9; if less than -0-, enter -0-) ...............10.                                                              . 
 
                                                                                                                                                                                           00 
    11. Interest penalty on underpayment of estimated tax (attach Ohio IT/SD 2210) ........................................11.                                                             . 
  12. Sales and use tax due on Internet, mail order or other out-of-state purchases (see instructions). 
                                                                                                                                                                                           00 
    If you certify that no sales or use tax is due, check the box to the right ........................................                      ...12.                                        . 
                                                                                                                                                                                           00 
 13. Total Ohio tax liability before withholding or estimated payments (add lines 10, 11 and 12) ................13.                                                                       . 
                                                                                                                                                                                           00 
  14. Ohio income tax withheld (W-2, box 17; W-2G, box 15; 1099-R, box 12) ................................................14.                                                             . 
 15. Estimated and extension payments made (2015 Ohio IT 1040ES and/or IT 40P) and credit  
                                                                                                                                                                                           00 
    carryforward from previous year return ......................................................................................................15.                                       . 
                                                                                                                                                                                           00 
  16. Refundable credits (attach Ohio Schedule of Credits, line 41) .................................................................16.                                                   . 
                                                                                                                                                                                           00 
 17. Amended return only – amount previously paid with original/amended return ......................................17.                                                                   . 
                                                                                                                                                                                           00 
 18. Total Ohio tax payments (add lines 14, 15, 16 and 17) .........................................................................18.                                                    . 
                                                                                                                                                                                           00 
 19. Amended return only – overpayment previously received on original/amended return .........................19.                                                                         . 
                                                                                                                                                                                           00 
  20. Line 18 minus line 19 ...............................................................................................................................20.                             . 
 
           If line 20 is MORE THAN line 13, skip to line 24. OTHERWISE, continue to line 21. 

                                                                                                                                                                                           00 
  21. Tax liability (line 13 minus line 20) ............................................................................................................21.                                . 
                                                                                                                                                                                           00 
 22. Interest and penalty due on late ﬁ ling or late payment of tax (see instructions) ...........................................................22.                                      . 
 23. TOTAL AMOUNT DUE (line 21 plus line 22). Enclose Ohio IT 40P (if original return) or IT 40XP 
                                                                                                                                                                                           00 
    (if amended return) and make check payable to “Ohio Treasurer of State”  .....................................23.                                                                      . 
                                                                                                                                                                                           00 
  24. Overpayment (line 20 minus line 13) ........................................................................................................24.                                      . 
 
                                                                                                                                                                                           00 
 25. Original return only  – amount of line 24 to be credited toward 2016 income tax liability .........................25.                                                                . 
  26. Amount of line 24 to be donated: 
    a. Military injury relief       b. Ohio History Fund          c. State nature preserves 
                         00                               00                          00 
                        .                           .                          . 
    d. Breast / cervical cancer     e. Wishes for Sick Children   f. Wildlife species 
                         00                               00                          00                                                                                                   00 
                        .                           .                          .             Total.......26g.                                                                              . 
 27. YOUR REFUND (line 24 minus lines 25 and 26g) ...................................................................................27.                                                   . 00 
  Sign Here (required): I have read this return. Under penalties of perjury, I declare that, to                                             If your refund is $1.00 or less, no refund will be issued. 
  the best of my knowledge and belief, the return and all enclosures are true, correct and complete.                                        If you owe $1.00 or less, no payment is necessary. 
                                                                                                                                                      NO Payment Enclosed   Mail–      to: 
  Your signature                                                              Date (MM/DD/YYYY)                                                               Ohio Department of Taxation 
                                                                                                                                                               P.O. Box 2679 
                                                                                                                                                               Columbus, OH  43270-2679 
  Spouse’s signature (see instructions)                                       Phone number 
                                                                                                                                                               Payment Enclosed  –Mail to: 
                                                                                                                                                               Ohio Department of Taxation 
       Preparer’s printed name (see instructions)   PTIN                       Phone number                                                                    P.O. Box 2057 
      Do you authorize your preparer to contact us regarding this return?      Yes    No                                                                       Columbus, OH  43270-2057 

                                                                               2015 Universal IT 1040 – page 2 of 2 

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Depa~ment of
* Ohio I Taxation 2015 Ohio Schedule A
Rev. 11/15 Income Adjustments – Additions and Deductions 1111111111 1111 1111111111 *
Social Security no. of primary ﬁler 

Additions
(add income items only to the extent not included on Ohio IT 1040, line 1)
00
1. Non-Ohio state or local government interest and dividends ..................................................................... 1. .
2. Certain Ohio pass-through entity and ﬁ nancial institutions taxes paid ...................................................... 2. . 00
3. Reimbursement of college tuition expenses and fees deducted in any previous year(s) and
noneducation expenditures from a college savings account .................................................................... 3. . 00
00
4. Losses from sale or disposition of Ohio public obligations ....................................................................... 4. .

00
5. Nonmedical withdrawals from a medical savings account ........................................................................ 5. .
6. Reimbursement of expenses previously deducted for Ohio income tax purposes, but only if the 00
reimbursement is not in federal adjusted gross income ............................................................................ 6. .
00
7. Lump sum distribution add-back ............................................................................................................... 7. .
Federal
00
8. Adjustment for Internal Revenue Code sections 168(k) and 179 depreciation expense .......................... 8. .
00
9. Federal interest and dividends subject to state taxation ........................................................................... 9. .
00
10. Miscellaneous federal income tax additions ........................................................................................... 10. .
00
11. Total additions (add lines 1 through 10 ONLY). Enter here and on Ohio IT 1040, line 2a) ..........11. .

Deductions
(deduct income items only to the extent included on Ohio IT 1040, line 1)

00
12. Business income deduction (attach Ohio Schedule IT BUS, line 11) ...................................................... 12. .

13. Employee compensation earned in Ohio by full-year residents of neighboring states ............................. 13. . 00
14. State or municipal income tax overpayments shown on IRS form 1040, line 10 .................................... 14. . 00
00
15. Qualifying Social Security beneﬁts and certain railroad retirement beneﬁ ts ........................................... 15. .
16. Interest income from Ohio public obligations and from Ohio purchase obligations; gains from the
sale or disposition of Ohio public obligations; public service payments received from the state of
00
Ohio or income from a transfer agreement ............................................................................................. 16. .
00
17. Amounts contributed to an individual development account ................................................................... 17. .
Federal
00
18. Federal interest and dividends exempt from state taxation .................................................................... 18. .
00
19. Adjustment for Internal Revenue Code sections 168(k) and 179 depreciation expense ........................ 19. .
20. Refund or reimbursements shown on IRS form 1040, line 21 for itemized deductions claimed on a
00
prior year federal income tax return ........................................................................................................ 20. .
00
21. Repayment of income reported in a prior year ........................................................................................ 21. .
22. Wage expense not deducted due to claiming the federal work opportunity tax credit ............................ 22. . 00

23. Miscellaneous federal income tax deductions ........................................................................................ 23. . 00

2015 Ohio Schedule A – pg. 1 of 2

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Depa~ment of
* Ohio I Taxation 2015 Ohio Schedule A
Rev. 11/15 Income Adjustments – Additions and Deductions 1111111111 11111111111111 *
Social Security no. of primary ﬁler 

Uniformed Services
24. Military pay for Ohio residents received while the military member was stationed outside Ohio ............ 24. . 00
00
25. Certain income earned by military nonresidents and civilian nonresident spouses .................................. 25. .
00
26. Uniformed services retirement income ................................................................................................... 26. .
00
27. Military injury relief fund ...................................................................................................................................... 27. .
00
28. Certain Ohio National Guard reimbursements and beneﬁ ts ................................................................... 28. .

Education
00
29. Ohio 529 contributions, tuition credit purchases ..................................................................................... 29. .
00
30. Pell/Ohio College Opportunity taxable grant amounts used to pay room and board .............................. 30. .
Medical
00
31. Disability and survivorship beneﬁts (do not include pension continuation beneﬁ ts) ............................... 31. .
32. Unreimbursed long-term care insurance premiums, unsubsidized health care insurance premiums 00
and excess health care expenses (see instructions for worksheet) ........................................................ 32. .
33. Funds deposited into, and earnings of, a medical savings account for eligible health care expenses 00
(see instructions for worksheet) .............................................................................................................. 33. .
00
34. Qualiﬁ ed organ donor expenses (maximum $10,000 per taxpayer) .................................................... 34. .
00
35. Total deductions (add lines 12 through 34 ONLY). Enter here and on Ohio IT 1040, line 2b .............35. .

2015 Ohio Schedule A – pg. 2 of 2

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                                                          Do not use staples. Use only black ink. 
                           Depa~ment of 
*  Ohio I Taxation                              2015 Ohio Schedule of Credits                                                                                                                    *  
                           Rev. 10/15                     Nonrefundable and Refundable                                                                                 11111111111111111 1111111 
                                                                                                                                                                          
                                                          Social Security no. of primary ﬁler 

                                                Nonrefundable Credits
                                                                                                                                                                                         00 
   1. Tax liability before credits (from Ohio IT 1040, line 8c) ............................................................................... 1.                                       . 
   2.   Retirement income credit (limit $200 per return). See the table in the instructions ................................... 2.                                                       . 00 
   3.  Lump sum retirement credit (attach Ohio LS WKS, line 6)… .................................................................... 3.                                                  . 00 
                                                                                                                                                                                         00 
   4.  Senior citizen credit (must be 65 or older to claim this credit; limit $50 per return) ................................ 4.                                                        . 
 
                                                                                                                                                                                         00 
   5.  Lump sum distribution credit (must be 65 or older to claim this credit; attach Ohio LS WKS, line 3)… .... 5.                                                                      . 
                                                                                                                                                                                         00 
   6.  Child care and dependent care credit (see the worksheet in the instructions)… ...................................... 6.                                                           . 
 
                                                                                                                                                                                         00 
   7.  If Ohio IT 1040, line 5 is $10,000 or less, enter $88; otherwise, enter -0- (low income credit) ................. 7.                                                              . 
   8.  Displaced worker training credit (see the worksheet in the instructions) (limit $500 per 
                                                                                                                                                                                         00 
       taxpayer) .................................................................................................................................................. 8.                   . 
   9.  Ohio political contributions credit (limit $50 per taxpayer); and credit for contributions to candidates                                                                          00 
     for Ohio statewide ofﬁce or General Assembly ......................................................................................... 9.                                           . 
                                                                                                                                                                                         00 
   10.  Income-based exemption credit ($20 personal/dependent exemption credit) ........................................ 10.                                                             . 
 
                                                                                                                                                                                         00 
  11.  Total (add lines 2 through 10) ................................................................................................................. 11.            , ,               . 
  12.  Tax less credits (line 1 minus line 11; if less than -0-, enter -0-) ............................................................. 12.                                            . 00 
 13.  Joint ﬁ ling credit. See the instructions for eligibility and documentation requirements. This credit is for                                                                       00 
       married      ﬁling jointly status only.  % times amount on line 12 (limit $650) ................................................13.                                               . 
                                                                                                                                                                                         00 
  14.  Earned income credit .............................................................................................................................. 14.                           . 
                                                                                                                                                                                         00 
  15.  Ohio adoption credit (limit $10,000) ....................................................................................................... 15.                                  . 
                                                                                                                                                                                         00 
  16.  Job retention credit, nonrefundable portion (enclose a copy of the credit certiﬁ cate) ............................. 16.                                                          . 
                                                                                                                                                                                         00 
  17.  Credit for eligible new employees in an enterprise zone ........................................................................ 17.                                              . 
                                                                                                                                                                                         00 
  18.  Credit for certiﬁed ethanol plant investments .......................................................................................... 18.                                      . 
                                                                                                                                                                                         00 
  19.  Credit for purchases of grape production property ................................................................................. 19.                                           . 
  20.  Credit for investing in an Ohio small business ........................................................................................ 20.                                       . 00 

                                                                                                                                                                                         00 
  21.  Enterprise zone day care and training credits ......................................................................................... 21.                                       . 
                                                                                                                                                                                         00 
  22.  Research and development credit .......................................................................................................... 22.                                    . 
                                                                                                                                                                                         00 
  23.  Ohio historic preservation credit, nonrefundable carryforward portion ................................................... 23.                                                     . 
  24.  Total (add lines 13 through 23) ............................................................................................................... 24.                               . 00 

                                                                                                                                                                                         00 
  25. Tax less additional credits (line 12 minus line 24; if less than -0-, enter -0-) ........................................... 25.                                                   . 

                                                Do not write in this area; for department use only. 

                                                2015 Ohio Schedule of Credits – pg. 1 of 2 

*                                                                                                                                                                                                *

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Depa~ment of
* Ohio I Taxation 2015 Ohio Schedule of Credits *
Rev. 10/15 Nonrefundable and Refundable Ill II Ill1111111111111111
Social Security no. of primary ﬁler 

Nonresident Credit
Date of nonresidency to State of residency
26. Enter the portion of Ohio adjusted gross income (Ohio
IT 1040, line 3) that was not earned or received in
00
Ohio. Attach Ohio IT NRC if required .................................26. .
27. Enter the Ohio adjusted gross income (Ohio IT 1040,
line 3) ....................................................................................27. . 00

28. Divide line 26 by line 27 and enter the result here (four digits; do not round). . 00
Multiply this factor by the amount on line 25 to calculate your nonresident credit .................................... 28. .
Resident Credit
29. Enter the portion of Ohio adjusted gross income (Ohio
IT 1040, line 3) subjected to tax by other states or the
District of Columbia while you were an Ohio resident
(limits apply) ..................................................................... 29. . 00
30. Enter the Ohio adjusted gross income (Ohio IT 1040,
line 3) .............................................................................30. . 00
31. Divide line 29 by line 30 and enter the result here (four digits; do not round)..
Multiply this factor by the amount on line 25
and enter the result here ................................................31. 00
.
32. Enter the 2015 income tax, less all credits other than
withholding and estimated tax payments and overpayment
carryforwards from previous years, paid to other states or
the District of Columbia (limits apply) ............................. 32. . 00
33. Enter the smaller of line 31 or line 32. This is your Ohio resident tax credit. If you ﬁled a return for
2015 with a state(s) other than Ohio, enter the two-letter state abbreviation in the box(es) below ........ 33. . 00

Grants
34. Manufacturing equipment grant .............................................................................................................. 34. . 00
35. Total nonrefundable credits and grants (add lines 11, 24, 28, 33 and 34; enter here and on Ohio
IT 1040, line 9) ........................................................................................................................................ 35. . 00

Refundable Credits
00
36. Historic preservation credit ..................................................................................................................... 36. .
00
37. Business jobs credit ................................................................................................................................... 37. .
00
38. Pass-through entity credit ....................................................................................................................... 38. .
39. Motion picture production credit .............................................................................................................. 39. . 00
00
40. Financial Institutions Tax (FIT) credit ...................................................................................................... 40. .
00
41. Total refundable credits (add lines 36 through 40; enter here and on Ohio IT 1040, line 16) .............. 41. .

2015 Ohio Schedule of Credits – pg. 2 of 2

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                               Do not use staples. Use only black ink and UPPERCASE letters. 

*         Depa!1ment of        2015 Schedule J – Dependents Claimed                                                                      *  
   Ohio I Taxation 
        Rev. 10/15                            on the Universal IT 1040 Return                    11111111111111111               1111111 
                                               Social Security no. of primary ﬁler                

Do not list below the primary ﬁ ler and/or spouse reported on Ohio IT 1040. 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” below if there are  
not enough boxes to spell it out completely. 
 1. Dependent’s Social Security no. (required) Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name                      M.I.  Last name 

2. Dependent’s Social Security no. (required)  Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name                      M.I.  Last name

3. Dependent’s Social Security no. (required)  Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name                      M.I.  Last name

4. Dependent’s Social Security no. (required)  Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name                      M.I.  Last name

5. Dependent’s Social Security no. (required)  Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name                      M.I.  Last name

6. Dependent’s Social Security no. (required)  Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name                      M.I.  Last name

7. Dependent’s Social Security no. (required)  Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name                      M.I.  Last name

                                             Do not write in this area; for department use only. 

                                               2015 Schedule J – pg. 1 of 2 

*                                                                                                                                        *

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*         Depa~ment of         2015 Schedule J – Dependents Claimed 
   Ohio I Taxation 
        Rev. 10/15                               on the Universal IT 1040 Return         Ill II Ill I 111111111111111               *  
                                                  Social Security no. of primary ﬁler           

Do not list below the primary ﬁ ler and/or spouse reported on Ohio IT 1040. 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” below if there are  
not enough boxes to spell it out completely.  
8. Dependent’s Social Security no. (required)     Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name                         M.I.  Last name 

9. Dependent’s Social Security no. (required)     Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name                         M.I.  Last name

  10. Dependent’s Social Security no. (required)  Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name                         M.I.  Last name

  11.  Dependent’s Social Security no. (required) Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name                         M.I. Last name 

  12. Dependent’s Social Security no. (required)  Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name                         M.I.  Last name

  13. Dependent’s Social Security no. (required)  Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name                         M.I.  Last name

  14. Dependent’s Social Security no. (required)  Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name                         M.I.  Last name

15. Dependent’s Social Security no. (required)    Dependent's date of birth (MM/DD/YYYY) Dependent’s relationship to you (required) 

   Dependent’s ﬁ rst name                         M.I.  Last name

                                                  2015 Schedule J – pg. 2 of 2 

*                                                                                                                                   *

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                        Electronic Payment Available                                                                                                                                                                                                              2015 Ohio IT 40P 
      You can eliminate writing a paper check by using any of 
      our electronic payment methods. Go to our Web site at 
      tax.ohio.gov for all electronic payment options. 

                            Federal Privacy Act Notice 
      Because we require you to provide us with a Social Se-
      curity number, the                                     Federal Privacy Act of 1974 requires 
      us to inform you that providing us with your Social Secu-
      rity 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. 

OHIO IT 40P                                                                                                                                                                                                                         Taxable Year   Do NOT fold check or voucher. 
                                                                                                                                                              DO NOT STAPLE                                                                                                                              *  
Income Tax Payment Voucher                                                                                                                                    YOUR PAYMENT TO                                                                                         Please use UPPERCASE letters
l,l,,l,,ll,,,l,l,,,lll,,l,,,,ll,l,l,11,,,,,l,l,l,,II                                                                                                     DOTHISNOTVOUCHER.SEND CASH.                                                2015                             to print the ﬁ rst three lettersof
First name                                                                                                  M.I.                   Last name                                                                                                                        Taxpayer’s           Spouse’s last name 
                                                                                                                                                                                                                                                                    last name            (only if joint ﬁling)
Spouse’s ﬁ               rst name (only if joint ﬁling)                                                     M.I.                   Last name 
                                                                                                                                                                                                                                            Your Social 
                                                                                                                                                                                                                                                   Security
Address                                                                                                                                                                                                                                            number 
                                                                                                                                                                                                                                            Spouse’s Social 
                                                                                                                                                                                                                                            Security number
City, state, ZIP code                                                                                                                                                                                                                       (only if joint ﬁling) 

                                                                                                                                                                                                                                                                                                0 0 
IfIfofyouyouState)arearewithsendingsendingyourONLYthisincomevoucher thistaxvoucherreturn,and paperandmailpapercheckto thecheckoraddressmoneyor moneyshownorderorder(payableon pageseparatelyto2 ofOhioOhioTreasurerfromIT 1040. the AMOUNTPAYMENTOF        $                                   .
                                                                                                                                                                                                                                                                 i                                      i 
return, then mail this voucher and payment to Ohio Department of Taxation, P.O. Box 182131,  
Columbus, OH 43218-2131. 
                                                                                                                                                                      402 
*

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