VILLAGE OF BLUFFTON, OHIOForm R-1 (Rev: 18A)File with: Your Soc. Sec. #:Bluffton Income Tax Department

P.O. Box 228Bluffton, OH 45817-0228

Spouse Soc. Sec. #:Business Fed. ID #:or

Fiscal Tax Year - for Businessesfrom: to: DID YOU MOVE DURING THE YEAR? ________

I MOVED INTO BLUFFTON I MOVED OUT OF BLUFFTON

DUE DATES: For CALENDAR Year Filings:

April 15thor

For FISCAL Year FIilings: 3 1/2 months after the end of the above fiscal year period.

DATE OF MOVE:PREVIOUS ADDRESS or NEW FORWARDING:ADDRESS

Address Line-1CURRENT NAME AND ADDRESS:Address Line-2

Your Name.........City, St.ZipCode

Spouse Name..IF YOU RENT, PLEASE PROVIDE THE NAME & ADDRESS OF YOUR LANDLORD.

Address Line-1.Landlord Name

Address Line-2....Address Line-1

City, St. ZipCode.Address Line-2

City, St.ZipCode

I am not required to complete this tax return because: (If applicable, check the item below that applies, sign the bottom of this page and file form by due date)

Total/permanent disability1. Retirement income only3.Moved out prior to above Tax Year, give date:2.4. Taxpayer deceased, give date: Only income is from non-taxable source, list source:5.

SECTION A: W-2 WAGES & BUSINESS INCOME No. of Different Employers / No. of W-2s Attached:________1)2)3)4)

5)6)7)8)9)

% of line 8 abv)

10)11)

SECTION B: INCOME TAX OWED & TAX CREDIT12)

17)18)19)20)21)22)23)

24)25)26)

13)14)15)16)

23)

SECTION C: DECLARATION OF ESTIMATED TAX(from page 3 Estimated Tax Worksheet, line 7)

IMPORTANT: All appropriate supporting documentation must be attached before this return will be processed. The undersigned declares that this return and attached supporting documentation is a true, correct and complete return for the taxable period stated and that the figures used herein are the same as what was used for federal income tax purposes. I authorize the Bluffton Income Tax Department to discuss my account, this return and supporting documentation with my preparer. I understand that this return is subject to further review by the Bluffton Income Tax Department and that I will be notified if any corrections are made or any additional tax balance is due. THE RETURN MUST BE SIGNED AND DATED TO BE A VALID FILING.

Signature of Taxpayer DateTitle, if Business Return

Date

Name of Individual & Company Preparing Return (Please print)

Signature of Spouse Date Signature of Person Preparing Return

Phone Number of PreparerTaxpayer Phone Number

INCOME TAX RETURN for Calendar Tax Year

1) Enter Total GROSS Wages Earned (Use the larger amount in box 5 or 18 on your W-2s.)2) Less Employee Business Expenses from Federal Form 2106 (Attach copy of your Federal Form 2106)3) Less Non-Resident Income, if Part Year Resident (Create & attach a worksheet explaining calculation)4) Calculate Taxable Wages (Subtract lines 2 and 3 from line 1. If no other income, take total to line 11.)5) Enter Total Business Income (From page 2, line 5. Attach Fed. Schedules.)6) Enter Adjustments to Business Income (From page 2, line 6)7) Calculate Adjusted Business Income (Add lines 5 and 6)8) Calculate Amt Allocable to Bluffton (From pg 2, line 8)9) Less Net Loss From Previous Returns (From page 2, line 9)

10) Calculate Taxable Business Income (Subtract line 9 from line 7 or 8)11) Total Taxable Income (Add lines 4 and 10)

12) Bluffton Income Tax (Multiply line 11 by Bluffton's Income Tax rate of .0125 or 1.25%)13) Less Bluffton Tax Withheld (Look for Bluffton city tax in box 19&20 on your W-2s)14) Less Credit Carry-over(Enter overpayment from prior yr being carried over to this yr.)15) Less Estimated Tax Paid (Enter total amt of est. pymts made during year)16) Less Other City Tax Withheld(Enter other city tax withheld. Cannot exceed 1.25% per W-2)17) Total Credits Allowable (Add lines 13, 14, 15, and 16)18) Tax Due (If line 12 is greater than 17, subtract line 17 from line 12. If not go to step 23)19) Late Filing Penalty (A $25 per month fee will be imposed on returns filed after the due date, up to a max of $150)20) Late Payment Penalty (A one-time late pymt penalty equal to 15% of amt not paid by the due date will be imposed.)21) Interest (Interest will be charged at a rate of: .417% for 2016, .50% for 2017 & 2018, .583% for 2019 & 2020.22) Total Due (Add lines 18, 19, 20, and 21) (Payment must accompany return & be payable to: Village of Bluffton)

Overpayment (If line 17 is greater than line 12, subtract line 12 from 17, then subtract lines 19, 20 and 21 from 17)23A)23A) Refund Requested (Enter birth date if under age 18)

23B) Amount to be Credited to Next Year's Tax Return 23B)

24) Total Estimated Tax declared for next tax YEAR.25) Amount Paid With This Estimate (from page 3 Estimated Tax Worksheet, line 8)26) Total Tax & Estimated Payment Due (Add lines 22, and 25)

NOTE: Before remitting, be sure all supplemental documents (W-2, SCH C, SCH E, K-1, 1099 MISC, etc.) are attached to your return. RETURNS WILL NOT BE PROCESSED IF THE SUPPORTING DOCUMENTATION IS MISSING.

NOTE: Return must be signed & dated to be a valid filing.

20 ____

Staple supporting documentation to the back of this return in the upper

left-hand corner.

NOTE: No payment is due or refund will be issued if

LESS THAN $10.00

Taxpayer Social Security No (from Page 1):

PAGE 2 - BUSINESS INCOME & ADJUSTMENTS (ALL APPROPRIATE FEDERAL SCHEDULES MUST BE ATTACHED)

LINE 5 - ENTER THE TOTAL OF THIS SECTION ON PAGE 1, SECTION A, LINE 5 - TOTAL BUSINESS INCOME

Schedule 4797 (depreciation recapture) . . . . . . . . . . . Schedule 1099 MISC, K-1 . . . . . . . . . . . . . . . . . . . . . .

Schedule MISC (From line21 on 1040). . . . . . . . . . . . . TOTAL OF LINE 5

NET TOTAL INCOME OTHER THAN WAGES (TO PAGE 1, SECTION A, LINE 5)

LINE 6 - ENTER THE TOTAL OF THIS SECTION ON PAGE 1, SECTION A, LINE 6 - ADJUSTMENTS TO BUSINESS INCOME (USE ONLY IF THESE INCOME ITEMS ARE INCLUDED IN THE SCHEDULES MARKED ABOVE - LINE 5)

ADDITEMS NOT DEDUCTIBLE DEDUCTITEMS NOT TAXABLE

N. CAPITAL GAINS (IRC 1221 or 1231) property dis- positions except to the extent the income and gains apply to those described in IRC 1245 or 1250

O. Federally reported intangible income such as, butnot limited to interest dividends, and patent andcopyright income

P. Amount of Federal Tax Credits to the extent theyhave reduced corresponding operating expenses

Q. Not Previously deducted IRC Sec. 179 expenses

S. Other

T. Total Lines N through S.

NET TOTAL OF J & T

NET TOTAL ADJUSTMENT TO INCOME (TO PAGE 1, SECTION A, LINE 6)

B. LOCATED IN BLUFFTON

C. PERCENTAGE(B DIVIDED BY A)

A. LOCATED EVERYWHERE

Step 1. Average value real and tangible personal property.. . . . . . . . . . .

Gross Annual rentals multiplied by 8. . . . . . . . . . . . . . . . . . . . . .

Total Step 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

%ALLOCABLE %

NET TOTAL AVERAGE PERCENTAGE ('Total of percentages' divided by number of steps checked) (TO PAGE 1, SECTION A, LINE 8) %

(enter as negative figures)LINE 9 - NET OPERATING LOSS DEDUCTION FROM PRIOR VILLAGE RETURNS (attach NOL schedule)

FIFTH PRECEDING YEAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ENTER 'NOL' TO OFFSET BUSINESS INCOME:

'NOL' USED THIS RETURN

TOTAL NET OPERATING LOSS AVAILABLE (TO PAGE 1, LINE 9)

Schedule C, E, and/or F. . . . . . . . . . . . . . . . . . . . . . . .

Schedule 1041, 1065, 1120, or 1120S. . . . . . . . . . . . .

Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

A. CAPITAL LOSSES (IRC 1221 or 1231 propertydispositions)

B. Five percent (5%) of intangible income reported inletter 0, except that from IRC 1221 propertydispositions

C. Taxes based on income (State)

D. Taxes based on income (City)

E. Guaranteed payments or accruals to or for currentor former partners or members

F. Federally deducted dividends, distributions, oramounts set aside for, credited to, or distributed toREIT or RIC investors

G. Federally deducted amounts paid or accrued to orfor qualified self employed retirement plans, healthinsurance plans, and life insurance plans forowners or owner-employee of non-C corporationentities

H. Rental activities by partnership, S Corp, LLC,trusts

I. Other

J. Total lines A through I

R. Partnership, S Corp, LLC. charitable contributions

Step 2. Gross receipts from sales or services . . . . . . . . . . . . . . . . . . . . .

Step 3. Total wages, salaries and other comp paid. .. . . . . . . . . . . . . . . . Total of percentages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

FOURTH PRECEDING YEAR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . THIRD PRECEDING YEAR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SECOND PRECEDING YEAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PRECEDING YEAR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Form R-1 (Rev: 18A)

VILLAGE OF BLUFFTON, OHIO - Income Tax Return - Page 2

LINE 8 - APPORTIONMENT PERCENTAGE - ENTER THE PERCENTAGE FROM THIS SECTION ON PAGE 1, SECTION A, LINE 8Use only if you are a business that has been established/incorporated outside of Bluffton limits and performs some work inside of Bluffton limits.If you are a business established/incorporated inside of Bluffton limits, this allocation does not apply.(Each Step used must be selected via check box.)

Schedule C: Profit/Loss Statement from Business or ProfessionSchedule E: Rental and Other IncomeSchedule F: Farm Income

DO NOT REMIT DECLARATION WORKSHEET

VILLAGE OF BLUFFTON, OHDECLARATION OF ESTIMATED INCOME TAX

WORKSHEET

Ending:For Calendar Year: or for Fiscal Year: Beginning:

1. Enter your Estimated Income from Wages, Salaries, Commissions, Etc. for next year (before any payroll deductions) . . . . . . . $

RECORD OF ESTIMATED TAX PAYMENTSVoucherNumber AmountCheck #Date

Due: 04-15 Due: 9-15

Due: 06-15 2 Due: 12-15

Total:

8. Calculate the Amount due with this Estimate by dividing Line 7 by 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2. Enter your Estimated Net Rental and Other Income Amount for next year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.Enter your Estimated Net Profit (or Loss) from your Business for next year (If this is a loss, the loss can only be deducted from line 2 above).

$$$$$$$

4.Total Lines 1, 2 and 3 above to determine your Estimated Income Subject to Tax . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . 5. Multiply Line 4 by 1.25% or .0125 to determine your Estimated Tax that will be due next year. . . . . . . . . . . . . . . . . . . . . . . . . . 6. Enter the Estimated Amount of Local Tax you expect to be Withheld at 1.25%. (See General Information #6) . . . . . . . . . . . . . . 7. Enter the Estimated Tax Amount you expect to owe next year by subtracting Line 6 from Line 5 above . . . . . . . . . . . . . . . . . . . . . . . . .

VoucherNumber Date Check # Amount

1

4

3

Form R-1 (Rev: 18A)

VILLAGE OF BLUFFTON, OHIO DECLARATION OF

ESTIMATED INCOME TAX WORKSHEET

WHO NEEDS TO FILE A DECLARATION AND MAKE ESTIMATED INCOME TAX PAYMENTS: Every taxpayer having or anticipating income under withheld or no local withholding being withheld by their employer(s) should file a declaration if the amount owed in income tax is estimated to be two hundred dollars ($200) or more. Please complete the worksheet below to determine if you need to file a declaration and pay estimated tax payments for next year.

NOTE: Estimated Income Tax Vouchers can be found on the Village of Bluffton website by to going to: www:bluffton-ohio.com. Click on the Income Tax tab located on the black bar across the top of the home page. Select either "Individual or Business Tax Forms" as shown in the "Search Tax Forms" box located on the left-hand side of the screen. Scroll down the page to locate the "V-1 Estimated Tax Voucher" form for the appropriate tax year.

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