Generic IT 941X

           Month               Payment Date       Gross Payroll             Tax Withheld – Line 1                                 Payments – Line 2 
                                As Amended                                  Credit From Prior Year    
           January 
           February 
           March 
           April 
           May 
           June 
           July 
           August 
           September 
           October 
           November 
           December 
           Totals 

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IT 941X                                      Amended Ohio Employer’s Annual Reconciliation of Income Tax Withheld  
Rev. 10/14      OHIO IT 941X
                 Ohio Withholding Acct. No.                     Federal Employer ID No.                                Tax Year 

                                                                                         As Filed                                               As Amended 
Name                                                          1. Ohio income
                                                               tax withheld 
                                                              2. Previous
Address                                                        payments 
                                                              3. Balance
                                                               due          $                                                     $ 
City, state, ZIP code 
                                                              4. Credit 

                                                              5. Refund 
Signature of responsible party Title         Telephone number               DO NOT STAPLE OR OTHERWISE ATTACH YOUR CHECK OR CHECK STUB TO THIS FORM. DO NOT SEND 
                                                                            CASH. Return this form with check or money order made payable to Ohio Treasurer of State and mail to Ohio 
                                                                            Department of Taxation, P.O. Box 182667, Columbus, Ohio 43218-2667. 
Your Social Security number                  Date                             If your refund is less than $1.01, no refund will be issued. 
                                                                                        If you owe less than $1.01, no payment is necessary.