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

                                                     2015 Universal IT 1040 
                       Rev. 11/15
                                            Individual Income Tax Return 
                                                                                                                                                        
  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
                                                                                                                                                     ,       , 
 
  2a. Additions to federal adjusted gross income (attach Ohio Schedule A, line 11) ........................... 2a.                                                                00
                                                                                                                                           ,         ,       ,                .
 
  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
  4. Personal and dependent exemption deduction (if claiming dependent(s), attach Schedule J)..... 4.                                                                             00
                                                                                                                                                             ,                .
 
  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 

                                                          2015 Universal IT 1040 
                        Rev. 11/15                  Individual Income Tax Return 
                                                                                                                                                                          
   SSN 

                                                                                                                                                                                             00 
   7a. Amount from line 7 on page 1 .....................................................................................................7a.           ,                ,          ,        .
  
                                                                                                                                                                                             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.                    ,          ,        .
   13. Total Ohio tax liability before withholding or estimated payments (add lines 10, 11 and 12) ................13.                                                  ,          ,        . 00 
                                                                                                                                                                                             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.                               ,          ,        .
   19. Amended return only – overpayment previously received on original/amended return .........................19.                                                    ,          ,        . 00 
                                                                                                                                                                                             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. 

   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.                                      00 
                                                                                                                                                                        ,          ,        .
 23. TOTAL AMOUNT DUE (line 21 plus line 22). Enclose Ohio IT 40P (if original return) or IT 40XP 
    (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.                                           ,                    00 
   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 

                                                        Do not use staples. Use only black ink. 

                                                       2015 Ohio Schedule A 
                          Rev. 11/15           Income Adjustments – Additions and Deductions 
                                                                Social Security no. of primary filer                                                           

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

      4. Losses from sale or disposition of Ohio public obligations ....................................................................... 4.             , ,        . 00 
   
      5. Nonmedical withdrawals from a medical savings account ........................................................................5.                  , ,        . 00 
      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.             , ,        .
   
      7. Lump sum distribution add-back ............................................................................................................... 7. , ,        . 00 
      Federal 
                                                                                                                                                             ,        .
      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.                       ,                      , ,        . 00 

                                               Deductions 
                   (deduct income items only to the extent included on Ohio IT 1040, line 1) 
       
  12. Business income deduction (attach Ohio Schedule IT BUS, line 11) ...................................................... 12.                                      00 
                                                                                                                                                             ,        .
   
                                                                                                                                                             , 
    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 
                                                                                                                                                           , , 
    15. Qualifying Social Security benefits and certain railroad retirement benefi ts ........................................... 15.                                    00 
                                                                                                                                                           , ,        .
    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 
         Ohio or income from a transfer agreement ............................................................................................. 16.                    00 
                                                                                                                                                           , ,        .
    17. Amounts contributed to an individual development account ...................................................................17.                                00 
                                                                                                                                                           , ,        .
      Federal 
    18. Federal interest and dividends exempt from state taxation .................................................................... 18.                             00 
                                                                                                                                                           , ,        .
                                                                                                                                                                       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 
         prior year federal income tax return ........................................................................................................ 20.             00 
                                                                                                                                                           , ,        .
    21. Repayment of income reported in a prior year ........................................................................................ 21.                      00 
                                                                                                                                                           , ,        .
    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 

                                                   2015 Ohio Schedule A 
                      Rev. 11/15               Income Adjustments – Additions and Deductions 
                                                           Social Security no. of primary filer                                                                                   

 Uniformed Services 
                                                                                                                                                                                          00 
  24. Military pay for Ohio residents received while the military member was stationed outside Ohio ............24.                                                           , ,        .
                                                                                                                                                                                          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 

                                                        Do not use staples. Use only black ink. 

                                         2015 Ohio Schedule of Credits 
                  Rev. 10/15                            Nonrefundable and Refundable 
                                                                                                                                                                    
                                                        Social Security no. of primary filer 

                                         Nonrefundable Credits
 1. Tax liability before credits (from Ohio IT 1040, line 8c) ............................................................................... 1.                  , ,       . 00 
  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.                                                  . 
 
  11. Total (add lines 2 through 10) ................................................................................................................. 11.                  00 
                                                                                                                                                                  , ,       . 
  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 fi ling 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 

                                                            Do not use staples. Use only black ink. 

                                           2015 Ohio Schedule of Credits 
                         Rev. 10/15                         Nonrefundable and Refundable 
                                                              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 
                                                                                                                         00
  (limits apply) ..................................................................... 29.          ,   ,               .
  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 
                                                                                                                                                                               00 
     2015 with a state(s) other than Ohio, enter the two-letter state abbreviation in the box(es) below ........ 33.                                                , ,       .
 
Grants 
                                                                                                                                                                               00 
  34. Manufacturing equipment grant .............................................................................................................. 34.              , ,       .
   35. Total nonrefundable credits and grants (add lines 11, 24, 28, 33 and 34; enter here and on Ohio 
                                                                                                                                                                               00 
     IT 1040, line 9) ........................................................................................................................................ 35.  , ,       .

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

                                      2015 Ohio Schedule of Credits – pg. 2 of 2 

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

                               2015 Schedule J – Dependents Claimed 
Rev. 10/15                                    on the Universal IT 1040 Return 
                                                 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 

                               2015 Schedule J – Dependents Claimed 
Rev. 10/15                                      on the Universal IT 1040 Return 
                                                  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 

                                                                                                                                                                                                                                   424
                                                                                                                                                                                                                                                                                                                                                             Columbus, OH 43218-2131. 
                                                                                                                                                                                                                  return, then mail this voucher and payment to Ohio Department of Taxation, P.O. Box 182131, 
       0 0 .                                            ,                                      ,                                                                                                                 
                                                                                                                                                                                                                
                                                                                                                                            $                     AMOUNTPAYMENTOF                                  ofIfthisyouState)voucherarewithsendingandyourpaperthisincomevoucherchecktax return,orandmoneypapermailordercheckto theseparatelyaddressor moneyshownfromorderONLYtheon(payablepageIf you2toareofOhioOhiosendingTreasurerIT 1040. 

                                                                                                                                     (only if jointfi ling)                                                                                                                                                                                                            City, state, ZIP code 
                                                                                                                                            Security number
                                                                                                                                            Spouse’s Social 
                                                                                                                                                 number                                                                                                                                                                                                                                                    Address 
                                                                                                                                                 Security
                                                                                                                                                 Your Social 
                                                                                                                                                                                                                                          Last name                                     M.I.                                 rst name       (only if jointfiling)                             Spouse’s fi
(only if jointfi ling)                                                           last name 
Spouse’s last name                                                              Taxpayer’s                                                                                                                                                Last name                                     M.I.                                                                                                First name 
               first three letters of                             to print the                                                                                 2015                                                DOTHISNOTVOUCHER.SEND CASH. 
       Please use UPPERCASE letters                                                                                                                                                                                 YOUR PAYMENT TO                                                                                              for Amended Returns 
                                                                                                                                                                                                                                  DO NOT STAPLE                                                  Income Tax Payment Voucher 
                   Do NOT fold check or voucher.                                                                                                                  Taxable Year                                                                                                                                                              OHIO IT 40XP 

                                                                                                              IT 1040 income tax return. amendedfor an 
                                                         payment voucher if you are submitting a payment IT 40XPUse the 

                                                                                                                   IT 1040 income tax return. originalfor an 
                                                         payment voucher if you are submitting a payment IT 40PUse the 

                                                              Use the IT 40P payment voucher if you are submitting a payment 
                                                                                                                     for an original IT 1040 income tax return. 

                                                        Use the IT 40XP payment voucher if you are submitting a payment 
                                                                                                             for an amended IT 1040 income tax return. 

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
                                                                                                                                                 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 fi ling) 
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 fi ling) 

                                                                                                                                                                                                                                                                                                                                                                                                           0 0
IfofIf youyouState)arearewithsendingsendingyourONLYthisincomevoucher thistaxvoucherreturn,and paperandmailpapercheckto thecheckaddressor moneyor moneyshownorderorderon(payablepageseparately2toofOhioOhiofromTreasurerIT 1040.theAMOUNTPAYMENTOF                        $                                      ,                          ,                                              .
                                                                                                                                                                                                                                                  
return, then mail this voucher and payment to Ohio Department of Taxation, P.O. Box 182131,  
Columbus, OH 43218-2131. 
                                                                                                                                                                       402 

                                                                                                                       IT RE 
                                                                                                                       Rev. 10/15 

                                                            15270102 

                2015 Ohio IT RE – Reason and Explanation of Corrections 
                                           Note: For amended individual return only 
                          Please complete the Universal IT 1040 (checking the amended return box) and 
                     attach this form with documentation to support any adjustments to line items on the return. 
Taxpayer Social Security no. (required) 

First name                                           M.I.  Last name 

Reason(s): 
  Net operating loss carrybackIMPORTANT:(   Be sure to complete      Ohio Schedule of Credits, manufacturing equipment grant   
  and attach Ohio IT NOL, Net Operating Loss Carryback               increased 
  Schedule [available at tax.ohio.gov] and check the box on the      Ohio Schedule of Credits, manufacturing equipment grant   
  front of the IT 1040 indicating that you are amending for a NOL.)  decreased 
  Federal adjusted gross income decreased                            Ohio Schedule of Credits, refundable credit(s) increased 
  Federal adjusted gross income increased                            Ohio Schedule of Credits, refundable credit(s) decreased 
  Filing status changed                                              Ohio IT/SD 2210 interest penalty amount increased 
  Residency status changed                                           Ohio IT/SD 2210 interest penalty amount decreased 
                                                                      
  Exemptions increased (attach Schedule J)                           Ohio sales and use tax increased 
  Exemptions decreased (attach Schedule J)                           Ohio sales and use tax decreased 
  Ohio Schedule A, additions to income                               Ohio withholding increased 
  Ohio Schedule A, deductions from income                            Ohio withholding decreased 
                                                                      
  Ohio Schedule of Credits, nonrefundable credit(s) increased        Estimated and/or Ohio IT 40P amount or previous year      
  Ohio Schedule of Credits, nonrefundable credit(s) decreased        carryforward overpayment increased 
  Ohio Schedule of Credits, nonresident credit increased             Estimated and/or Ohio IT 40P amount or previous year      
  Ohio Schedule of Credits, nonresident credit decreased             carryforward overpayment decreased 
  Ohio Schedule of Credits, resident credit increased                Amount paid with original fi ling did not equal amount reported as 
                                                                     paid with the original filing 
  Ohio Schedule of Credits, resident credit decreased 

Detailed explanation of adjusted items (attach additional sheet(s) if necessary): 

E-mail address (optional)                                            Telephone number (optional) 

                                               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 informa-
                tion. We need your Social Security number in order to administer this tax. 

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