City of Fairfield
INCOME TAX DIVISION
701 Wessel Drive, Fairfield, Ohio 45014 513-867-5327 (TDD-867-5392)
APPLICATION FOR EXTENSION REQUEST
(Due on or before the Original Due Date of Return)
______________________ ______________________ ____________________
Original Due Date of Return Extension Date Requested Previous Extension Date
The undersigned taxpayer, or duly authorized agent for the taxpayer, hereby requests an
extension of time as indicated below within which to file an annual Fairfield Income Tax return,
form IR (Individual) or BR (Business), for the taxpayer account and number shown below. The
reason for this request is: (Note: 1 or 2 must be completed)
1. _____ An extension has been requested of the IRS for filing the federal income tax
return and the Fairfield extension would not be more than six (6) months beyond
the original due date of return.
2. _____ Other (explain): ___________________________________________________
NOTE: A copy of the Federal extension _________________________ ___________
must accompany extension or Signature of Requistioner Date
final return.
NAME OF TAXPAYER(S) EXTENSION REQUESTED FOR
: (All accounts are by SS# or FID#)
Taxpayer(s)
Address SS# or FID # (Required)
Reason(s) for Disapproval:
_____ Request received after due date for filing.
_____ Social Security Number or Federal Identification
Number not included.
_____ Taxpayer’s account is delinquent from prior years.
NOTE: An extension does not waive the tax due by April 15
th
,
an estimated liability amount must be paid-in at the time of the
extension request. Failure to do so will require our office to
assess interest as required under Section 181.10 of the
Fairfield Earned Income Tax Ordinance.
_____ Disapproved
_____ Approved
