PLEASE NOTE: File this form with the City of Dublin on or before the due date of the return and pay any amount you owe.
THIS IS NOT AN EXTENSION OF TIME TO PAY YOUR TAX
I request an automatic six month extension of time to file for the City of Dublin for Tax Year 2019
1. Total Dublin Tax Liability for Tax Year 2019 .................................................................................................................. $
2. Total payments and credits ........................................................................................................................................... ($ )
3. Balance Due for Tax Year 2019 (Subtract Line 2 from Line 1) ................................................................................... $
Declaration of estimated taxes for Tax Year 2020 (If liability to Dublin will exceed $200.00)
A. Estimated income subject to Dublin tax .......................................................$
1. Estimated tax due: 2% times Line A .................................................................................... $
B. DUBLIN tax to be withheld by employer .................................................................................... ($ )
C. Credit allowed for income taxed by other cities (Up to a 2% credit) ......................................... ($ )
D. DECLARATION OF ESTIMATED TAX DUE (Line Al less Lines B and C) ..................................... $
4. Amount of Declaration due for Tax Year 2020. (Enter 22.5% of Line D) ................................................................ $
Total Amount Due with this Form. (ADD Lines 3 and 4) ................................................................................................. $
IN ORDER TO RECEIVE AN EXTENSION, YOU MUST PAY IN FULL THE BALANCE DUE WITH THIS FORM
SIGNATURE AND VERIFICATION
Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the best of
my knowledge and belief, it is true, correct and complete and, if prepared by someone other than the taxpayer, that I am authorized to pre-
pare this form.
Signature of Taxpayer or Authorized Representatives Date
Signature of Spouse Date
NAME(S) SOCIAL SECURITY NO. OF TAXPAYER(S) OR FID #
ADDRESS
CITY, STATE, ZIP
INDIVIDUAL APPLICATION FOR
EXTENSION OF TIME TO FILE
INCOME TAX RETURN
FOR TAX YEAR 2019
File this Form On or Before
the Due Date of the Return
CITY OF DUBLIN, OHIO
DIVISION OF TAXATION
PO Box 9062
Dublin OH 43017-0962
Telephone (614) 410-4460
Toll Free (888) 490-8154
Fax (614) 923-5520
