Rev. 1/14 
                                                                                                 SV FBP 
                                                                                                 Request to File
                         Please do not                                                           By Paper 
                         use staples. 
Severance account number         FEIN/SSN 

Use only UPPERCASE letters.
Taxpayer's name 

Street address (number and street) 

City                                                                 State  ZIP code 

Contact's fi rst name                                 M.I. Last name

Telephone                                      Fax 

Title                                                                E-mail 

Ohio Revised Code section 5749.06 requires that all severance fi lers remit each tax payment and corresponding return electronically.  
Additionally, a person required by that section to remit taxes or fi le returns electronically may apply to the tax commissioner, on the 
form prescribed, to be excused from that requirement for good cause. 
Please describe in detail the reason(s) the above-referenced taxpayer requests to be excluded from the electronic fi ling requirement. 
The department will respond by letter indicating either approval or denial. 
 File by paper                    Pay by check              File by paper and pay by check 

SIGN HERE (required) 
I declare under penalty of perjury that I am the taxpayer or the taxpayer’s authorized agent having knowledge of the relevant facts in 
this matter to fi le this request to file by paper. 

 Signature Date (MM/DD/YY) 

 Name (print)                                                                              Title 

Taxpayer representative: The taxpayer will be represented in the matter by the following individual. Please attach a Declaration of 
Tax Representative (Ohio form TBOR 1), which can be found on the department’s Web site at tax.ohio.gov. 
First name                                           M.I. Last name

Telephone                                      Title 

E-mail 

                                        Please send this request to: Ohio Department of Taxation, 
                         Excise & Energy Tax Division – SV FBP, P.O. Box 530, Columbus, OH 43216-0530.