Fillable Form 21000106: 2021 Ohio IT 1040 If deceased (State of Ohio)

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Form 21000106: 2021 Ohio IT 1040 If deceased (State of Ohio)

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The Form 21000106: 2021 Ohio IT 1040 If deceased (State of Ohio) form is 19 pages long and contains:

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2021 Ohio IT 1040
Individual Income Tax Return
Use only black ink/UPPERCASE letters.
hio
Depart
ment of
Taxation
Sequence No. 1
Single, head of household or qualifying widow(er)
Married ling jointly
Married ling separately
StateCity
ZIP code
Ohio county (rst four letters)
Do not staple or paper clip.
1. Federal adjusted gross income (federal 1040 or 1040-SR, line 11). Place a "-" in the box
if negative ................................................................................................................................ ..1.
2a. Additions – Ohio Schedule of Adjustments, line 10 (include schedule) ....................................... 2a.
2b. Deductions – Ohio Schedule of Adjustments, line 39 (include schedule) ....................................2b.
3. Ohio adjusted gross income (line 1 plus line 2a minus line 2b). Place a "-" in the box
if negative ............................................................................................................................... ..3.
4. Exemption amount (include Schedule of Dependents if applicable) ............................................4.
Number of exemptions including you and your spouse/dependents, if applicable:
5. Ohio income tax base (line 3 minus line 4; if negative, enter zero)..................................................5.
6. Taxable business income – Ohio Schedule IT BUS, line 13 (include schedule) ............................6.
7. Taxable nonbusiness income (line 5 minus line 6; if negative, enter zero) ...................................... 7.
Filing Status – Check one (as reported on federal income tax return)
AMENDED RETURN - Check here and include Ohio IT RE.
Address line 1 (number and street) or P.O. Box
Primary taxpayer's SSN (required)
Spouse’s SSN (if filing jointly)
If deceased
School district #
Foreign country (if the mailing address is outside the U.S.) Foreign postal code
First name Last nameM.I.
Spouse's rst name (if ling jointly) Last nameM.I.
MM-DD-YY Code
Residency Status – Check only one for primary
Check only one for spouse (if ling jointly)
Resident
Part-year
resident
Nonresident
Indicate state

Resident
Part-year
resident
Nonresident
Indicate state

Address line 2 (apartment number, suite number, etc.)
Federal extension lers - check here.
If someone can claim you (or your spouse if ling jointly) as a
dependent, check here.
Do not staple or paper clip.
Ohio Nonresident Statement – See instructions for required criteria
Primary meets the ve criteria for irrebuttable presumption as nonresident.
Spouse meets the ve criteria for irrebuttable presumption as nonresident.
NOL CARRYBACK - Check here and include Schedule IT NOL.
If deceased
IT 1040 – page 1 of 2
Spouse’s SSN
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21000106
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Clear Form
Sequence No. 2
2021 Ohio IT 1040
Individual Income Tax Return
SSN
IT 1040 – page 2 of 2
If line 20 is MORE THAN line 13, skip to line 24. OTHERWISE, continue to line 21.
Preparer's printed name Phone number
Primary signature Phone number
Spouse’s signature
Date
Sign Here (required): I have read this return. Under penalties of perjury, I declare that, to the best of my knowledge
and belief, the return and all enclosures are true, correct and complete.
If your refund is $1.00 or less, no refund will be issued.
If you owe $1.00 or less, no payment is necessary.
NO Payment Included – Mail to:
Ohio Department of Taxation
P.O. Box 2679
Columbus, OH 43270-2679
Payment Included – Mail to:
Ohio Department of Taxation
P.O. Box 2057
Columbus, OH 43270-2057
Check here to authorize your preparer to discuss this return with the Department.
7a. Amount from line 7 on page 1 ........................................................................................................ 7a.
8a. Nonbusiness income tax liability on line 7a (see instructions for tax tables)...............................................8a.
8b. Business income tax liability – Ohio Schedule IT BUS, line 14 (include schedule) ..................................8b.
8c. Income tax liability before credits (line 8a plus line 8b) ..............................................................................8c.
9. Ohio nonrefundable credits – Ohio Schedule of Credits, line 38 (include schedule) ..................................9.
10. Tax liability after nonrefundable credits (line 8c minus line 9; if negative, enter zero) ................................10.
11. Interest penalty on underpayment of estimated tax (include Ohio IT/SD 2210) ........................................11.
12. Unpaid use tax (see instructions) ................................................................................................................12.
13. Total Ohio tax liability before withholding or estimated payments (add lines 10, 11 and 12) ...................13.
14. Ohio income tax withheld – Schedule of Ohio Withholding, part A, line 1 (include schedule and
income statements) ..................................................................................................................................14.
15. Estimated and extension payments (from Ohio IT 1040ES and IT 40P), and credit carryforward
from last year's return .................................................................................................................................15.
16. Refundable credits – Ohio Schedule of Credits, line 44 (include schedule) .............................................16.
17. Amended return only – amount previously paid with original and/or amended return .............................17.
18. Total Ohio tax payments (add lines 14, 15, 16 and 17) ............................................................................ 18.
19. Amended return only – overpayment previously requested on original and/or amended return .............. 19.
20. Line 18 minus line 19. Place a "-" in the box if negative ........................................................................ ....20.
21. Tax due (line 13 minus line 20). If line 20 is negative, ignore the "-" and add line 20 to line 13..................21.
22. Interest due on late payment of tax (see instructions) ..............................................................................................22.
23. TOTAL AMOUNT DUE (line 21 plus line 22). Include Ohio IT 40P (if original return) or IT 40XP
(if amended return) and make check payable to “Ohio Treasurer of State” ............... AMOUNT DUE.23.
24. Overpayment (line 20 minus line 13) ..........................................................................................................24.
25. Original return only – portion of line 24 carried forward to next year’s tax liability .....................................25.
26. Original return only – portion of line 24 you wish to donate:
a. Military Injury Relief b. Ohio History Fund c. Nature Preserves/Scenic Rivers
Total ....26g.
d. Breast/Cervical Cancer e. Wishes for Sick Children f. Wildlife Species
27. REFUND (line 24 minus lines 25 and 26g) .................................................................YOUR REFUND27.
Preparer's TIN (PTIN)
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21000206
2021 Ohio Schedule
of Adjustments
Use only black ink/UPPERCASE letters.
Sequence No. 3
Primary taxpayer’s SSN
Additions
(Only add the following amounts if they are not included on Ohio IT 1040, line 1)
1. Non-Ohio state or local government interest and dividends ....................................................................... 1.
2. Ohio pass-through entity taxes excluded from federal adjusted gross income .......................................... 2.
3. Ohio529planfundsusedfornon-qualiedexpenses ............................................................................... 3.
4. Losses from sale or disposition of Ohio public obligations ......................................................................... 4.
5. Nonmedical withdrawals from a medical savings account ......................................................................... 5.
6. Reimbursement of expenses previously deducted on an Ohio income tax return ..................................... 6.
Federal
7. Internal Revenue Code 168(k) and 179 depreciation expense addback ................................................... 7.
8. Exempt federal interest and dividends subject to state taxation ................................................................ 8.
9. Federal conformity additions ...................................................................................................................... 9.
10. Total additions (add lines 1 through 9 ONLY). Enter here and on Ohio IT 1040, line 2a ..............10.
Deductions
(Only deduct the following amounts if they are included on Ohio IT 1040, line 1)
11. Business income deduction – Ohio Schedule IT BUS, line 11 ................................................................. 11.
12. Employee compensation earned in Ohio by residents of neighboring states ............................................. 12.
13. Taxablerefunds,credits,orosetsofstateandlocalincometaxes(federal1040,Schedule1,line1) .. 13.
14. TaxableSocialSecuritybenets(federal1040and1040-SR,line6b) .................................................... 14.
15. Certainrailroadbenets ........................................................................................................................... 15.
16. Interest income from Ohio public obligations and purchase obligations; gains from the
disposition of Ohio public obligations; or income from a transfer agreement ........................................... 16.
17. Amounts contributed to an Ohio county's individual development account program ............................... 17.
18. Amounts contributed to a STABLE account: Ohio's ABLE plan ...............................................................18.
19. Income earned in Ohio by a qualifying out-of-state business or employee for disaster
work conducted during a disaster response period .................................................................................. 19.
Federal
20. Federal interest and dividends exempt from state taxation ...................................................................... 20.
21. Deduction of prior year 168(k) and 179 depreciation addbacks ............................................................... 21.
22. Refund or reimbursements from the federal 1040, Schedule 1, line 8z for federal
itemized deductions claimed on a prior year return .................................................................................. 22.
Schedule of Adjustments – page 1 of 2
21000306
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Sequence No. 4
2021 Ohio Schedule
of Adjustments
Primary taxpayer’s SSN
23. Repayment of income reported in a prior year ......................................................................................... 23.
24. Wage expense not deducted based on the federal work opportunity tax credit ....................................... 24.
25.
Federal conformity deductions ................................................................................................................... 25.
Uniformed Services
26. Military pay received by Ohio residents while stationed outside Ohio ....................................................... 26.
27. Compensation earned by nonresident military servicemembers and their civilian spouses ...................... 27.
28. Uniformed services retirement income ..................................................................................................... 28.
29. Military injury relief fund grants and veteran’s disability severance payments .................................................. 29.
30. CertainOhioNationalGuardreimbursementsandbenets ..................................................................... 30.
Education
31. Amounts contributed to Ohio CollegeAdvantage: Ohio’s 529 Plan .......................................................... 31.
32. Pell/Ohio College Opportunity taxable grant amounts used to pay room and board ............................... 32.
33. Ohio educator expenses in excess of federal deduction .......................................................................... 33.
Medical
34. Disabilitybenets ..................................................................................................................................... 34.
35.Survivorbenets ....................................................................................................................................... 35.
36. Unreimbursed medical and health care expenses (see instructions for worksheet; include a copy) ..... 36.
37. Medical savings account contributions/earnings (see instructions for worksheet; include a copy) ........ 37.
38. Qualiedorgandonorexpenses .............................................................................................................. 38.
39. Total deductions (add lines 11 through 38 ONLY). Enter here and on Ohio IT 1040, line 2b ...............39.
Schedule of Adjustments – page 2 of 2
21000406
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2021 Ohio Schedule IT BUS
Business Income
Sequence No. 5
Part 1 – Business Income From IRS Schedules
Note: Do not include amounts listed on the IRS schedules below that are nonbusiness income.
See R.C. 5747.01(C). If the amount on a line is negative, place a “-“ in the box provided.
1. Schedule B – Interest and Ordinary Dividends ...........................................................................................1.
2.ScheduleC–ProtorLossFromBusiness(SoleProprietorship).................................................. ....2.
3.ScheduleD–CapitalGainsandLosses ......................................................................................... ....3.
4.ScheduleE–SupplementalIncomeandLoss................................................................................ ....4.
5. Guaranteed payments or compensation from a pass-through entity to a 20% or greater direct
or indirect owner .........................................................................................................................................5.
6.ScheduleF–ProtorLossFromFarming ..................................................................................... ....6.
7. Other business income or loss not reported above (e.g. form 4797 amounts)
............................... ....7.
8. Total business income (add lines 1 through 7) ................................................................................ ....8.
Part 2 – Business Income Deduction
9. Enter the lesser of line 8 above or Ohio IT 1040, line 1. If negative, enter zero;
stop here and do not complete Part 3 ........................................................................................................9.
10. Enter$250,000iflingstatusissingleormarriedlingjointly;OR
Enter$125,000iflingstatusismarriedlingseparately .........................................................................10.
11.Enterthelesserofline9orline10.EnterhereandonOhioScheduleofAdjustments,line11 ......................11.
Part 3 – Taxable Business Income
Note: If Ohio IT 1040, line 5 is zero, do not complete Part 3.
12.Line9minusline11 ...................................................................................................................................12.
13. Taxable business income (enter the lesser of line 12 above or Ohio IT 1040, line 5). Enter here and
on Ohio IT 1040, line 6 ..............................................................................................................................13.
14. Business income tax liability – multiply line 13 by 3% (.03). Enter here and on Ohio IT 1040, line 8b .........14.
Enterallbusinessincomethatyou(andyourspouse,iflingjointly)receivedduringthetaxyearonthisschedule.Enteronlythoseamountsthatareincluded
inyourfederaladjustedgrossincome.Only one IT BUS should be used for each return led. See R.C. 5747.01(B).
Schedule IT BUS – page 1 of 2
21260106
Do not write in this area; for department use only.
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Use only black ink/UPPERCASE letters.
Primary taxpayer’s SSN
Part 4 – Business Sources
Listallsourcesofbusinessincome,withOhiosourceslistedrst.Alsoseparatelylistyourownershippercentageand/oryourspouse’sownershippercent-
age(iflingjointly).Ifnecessary,completeadditionalcopiesofthispageandincludewithyourreturn.
Spouse’s ownershipFEIN/SSN Primary ownership
Business name
2021 Ohio Schedule IT BUS
Business Income
Sequence No. 6
Primary taxpayer’s SSN
Schedule IT BUS – page 2 of 2
1.
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4.
5.
6.
7.
8.
Spouse’s ownershipFEIN/SSN Primary ownership
Business name
Spouse’s ownership
FEIN/SSN Primary ownership
Business name
Spouse’s ownershipFEIN/SSN Primary ownership
Business name
Spouse’s ownershipFEIN/SSN Primary ownership
Business name
Spouse’s ownershipFEIN/SSN Primary ownership
Business name
Spouse’s ownershipFEIN/SSN Primary ownership
Business name
Spouse’s ownershipFEIN/SSN Primary ownership
Business name
% %
% %
% %
% %
% %
% %
% %
% %
21260206
2021 Ohio Schedule of Credits
Use only black ink/UPPERCASE letters.
hio
Department of
Taxation
Sequence No. 7
Schedule of Credits – page 1 of 2
Nonrefundable Credits
1. Tax liability before credits (from Ohio IT 1040, line 8c) .............................................................................. 1.
2. Retirement income credit (see instructions for table; include 1099-R forms) ........................................... 2.
3. Lump sum retirement credit (see instructions for worksheet; include a copy) ....................................... 3.
4. Senior citizen credit (must be 65 or older to claim this credit) ................................................................. 4.
5. Lump sum distribution credit (see instructions for worksheet; include a copy) ...................................... 5.
6. Child care & dependent care credit (see instructions for worksheet; include a copy)......................... ... 6.
7. Displaced worker training credit (see instructions for all required documentation; include copies) ....... 7.
8. CampaigncontributioncreditforOhiostatewideoceorGeneralAssembly ......................................... 8.
9. Income-based exemption credit ($20 times the number of exemptions) ................................................. 9.
10. Total (add lines 2 through 9) .................................................................................................................. 10.
11. Tax less credits (line 1 minus line 10; if negative, enter zero) ................................................................ 11.
12. Jointlingcredit(seeinstructionsfortable).%timesline11,upto$650.......................................... .....12.
13. Earned income credit ............................................................................................................................. 13.
14. Home school expenses credit ................................................................................................................ 14.
15. Scholarship donation credit .................................................................................................................... 15.
16. Nonchartered, nonpublic school tuition credit ........................................................................................ 16.
17. Ohio adoption credit ............................................................................................................................... 17.
18. Nonrefundable job retention credit (include a copy of the credit certicate) ..................................... 18.
19. Credit for eligible new employees in an enterprise zone (include a copy of the credit certicate) ... 19.
20.Grapeproductioncredit .......................................................................................................................... 20.
21. InvestOhio credit (include a copy of the credit certicate) ................................................................ 21.
22. Lead abatement credit (include a copy of the credit certicate) ....................................................... 22.
23. Opportunity zone investment credit (include a copy of the credit certicate) ................................... 23.
24. Technology investment credit carryforward (include a copy of the credit certicate) ........................ 24.
25. Enterprise zone day care & training credits (include a copy of the credit certicate) ....................... 25.
26. Research & development credit (include a copy of the credit certicate) ......................................... 26.
Primary taxpayer’s SSN
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21280106
Do not write in this area; for department use only.
2021 Ohio Schedule of Credits
Sequence No. 8
Schedule of Credits – page 2 of 2
27. Nonrefundable Ohio historic preservation credit (include a copy of the credit certicate) ................ 27.
28. Total (add lines 12 through 27) .............................................................................................................. 28.
29. Tax less additional credits (line 11 minus line 28; if negative, enter zero).............................................. 29.
Dates of Ohio residency to Other state of residency
30.
Nonresident Portion of Ohio adjusted gross income -
Ohio IT NRC Section I, line 18 (include a copy)
............ 30.
31. Ohio adjusted gross income (Ohio IT 1040, line 3) ........ 31.
32a. Divide line 30 by line 31 (four decimals; do not round;
if greater than 1, enter 1.0000) ...................................................................... 32a.
32. Nonresident credit (line 29 times line 32a) ............................................................................................ 32.
Resident Credit
33. Portion of Ohio adjusted gross income taxed by another
state or the District of Columbia while an Ohio resident -
Ohio IT RC, line 1a (include a copy) .............................. 33.
34. Ohio adjusted gross income (Ohio IT 1040, line 3) ........ 34.
35a. Divide line 33 by line 34 (four decimals; do not round;
if greater than 1, enter 1.0000) ..................................................................... 35a.
35. Line 29 times line 35a ....................................................35.
36. 2021 income tax liability after credits paid to
another state or the District of Columbia -
Ohio IT RC, line 1b (include a copy) ..............................36.
37. Resident credit (enter the lesser of line 35 or line 36) Enter the two-letter state abbreviation
in the boxes below for each state in which income was subject to tax .................................................. 37.
38. Total nonrefundable credits (add lines 10, 28, 32 and 37; enter here and on Ohio IT 1040, line 9) .. 38.
Refundable Credits
39. Refundable Ohio historic preservation credit (include a copy of the credit certicate) ..................... 39.
40. Refundable job creation credit & job retention credit (include a copy of the credit certicate) ..................40.
41. Pass-through entity credit (include a copy of the Ohio IT K-1s) ......................................................... 41.
42. Motion picture & Broadway theatrical production credit (include a copy of the credit certicate) ..... 42.
43. Venture capital credit (include a copy of the credit certicate) ......................................................... 43.
44. Total refundable credits (add lines 39 through 43; enter here and on Ohio IT 1040, line 16) ............. 44.
Nonresident Credit
Primary taxpayer’s SSN
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21280206
Dependent's date of birth (MM-DD-YYYY)
Do not list the primary ler and/or spouse (if ling jointly) as dependents on this schedule. 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” if necessary.
1.
2.
3.
4.
5.
6.
7.
Dependent’s SSN
Dependent’s rst name Dependent's last nameM.I.
Dependent’s relationship to you
Dependent's date of birth (MM-DD-YYYY)
Dependent's last name
Dependent’s SSN
Dependent’s rst name M.I.
Dependent’s relationship to you
Dependent's date of birth (MM-DD-YYYY)Dependent’s SSN
Dependent’s rst name Dependent's last nameM.I.
Dependent’s relationship to you
Dependent's date of birth (MM-DD-YYYY)
Dependent's last name
Dependent’s SSN
Dependent’s rst name M.I.
Dependent’s relationship to you
Dependent's date of birth (MM-DD-YYYY)
Dependent's last name
Dependent’s SSN
Dependent’s rst name M.I.
Dependent’s relationship to you
Dependent's date of birth (MM-DD-YYYY)Dependent’s SSN
Dependent’s rst name Dependent's last nameM.I.
Dependent’s relationship to you
Dependent's date of birth (MM-DD-YYYY)
Dependent's last name
Dependent’s SSN
Dependent’s rst name M.I.
Dependent’s relationship to you
Rev. 08/10/21. Schedule of Dependents – page 1 of 2
Primary taxpayer's SSN
2021 Ohio Schedule
of Dependents
Use only black ink/UPPERCASE letters.
Sequence No. 9
21230106
Do not write in this area; for department use only.
8.
9.
10.
11.
12.
13.
14.
15.
Dependent's date of birth (MM-DD-YYYY)Dependent’s SSN
Dependent’s rst name Dependent's last nameM.I.
Dependent’s relationship to you
Dependent's date of birth (MM-DD-YYYY)
Dependent's last name
Dependent’s SSN
Dependent’s rst name M.I.
Dependent’s relationship to you
Dependent's date of birth (MM-DD-YYYY)
Dependent’s SSN
Dependent’s rst name Dependent's last nameM.I.
Dependent’s relationship to you
Dependent's date of birth (MM-DD-YYYY)
Dependent's last name
Dependent’s SSN
Dependent’s rst name M.I.
Dependent’s relationship to you
Dependent's date of birth (MM-DD-YYYY)
Dependent's last name
Dependent’s SSN
Dependent’s rst name M.I.
Dependent’s relationship to you
Dependent's date of birth (MM-DD-YYYY)
Dependent’s SSN
Dependent’s rst name Dependent's last nameM.I.
Dependent’s relationship to you
Dependent's date of birth (MM-DD-YYYY)
Dependent's last name
Dependent’s SSN
Dependent’s rst name M.I.
Dependent’s relationship to you
Dependent's date of birth (MM-DD-YYYY)
Dependent's last name
Dependent’s SSN
Dependent’s rst name M.I.
Dependent’s relationship to you
Primary taxpayer's SSN
Rev. 08/10/21. Schedule of Dependents – page 2 of 2
Sequence No. 10
2021 Ohio Schedule
of Dependents
21230206
Part A - Total Withholding
1. Total of all Ohio state tax withheld on pages 1 and 2 as well as any additional pages. Enter here
and on line 14 of your Ohio IT 1040 ...................................................................................................................1.
Box 2 - Federal income tax withheldBox 1 - Wages, tips, other compensation
P/S Box b - EIN
Box 15 - Employer’s Ohio ID number
Schedule of Withholding – page 1 of 2
List your and your spouse’s (if ling jointly) W-2, 1099, and W-2G forms only if they have Ohio withholding. Enter “P” in the “P/S” box if the form is the
primary taxpayer’s and enter “S” if it is the spouse’s. If the Ohio ID number on a statement has 9 digits, enter only the rst 8 digits. Complete additional
copies if necessary. Place state copies of your income statements after the last page of your return.
Box 16 - Ohio wages, tips, etc. Box 17 - Ohio income tax
Part B - W-2s
Box 2 - Federal income tax withheldBox 1 - Wages, tips, other compensation
P/S Box b - EIN
Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc. Box 17 - Ohio income tax
Box 2 - Federal income tax withheldBox 1 - Wages, tips, other compensation
P/S Box b - EIN
Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc. Box 17 - Ohio income tax
Box 2 - Federal income tax withheldBox 1 - Wages, tips, other compensation
P/S Box b - EIN
Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc. Box 17 - Ohio income tax
Box 2 - Federal income tax withheldBox 1 - Wages, tips, other compensation
P/S Box b - EIN
Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc. Box 17 - Ohio income tax
Box 2 - Federal income tax withheldBox 1 - Wages, tips, other compensation
P/S Box b - EIN
Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc. Box 17 - Ohio income tax
Box 2 - Federal income tax withheldBox 1 - Wages, tips, other compensation
P/S Box b - EIN
Box 15 - Employer’s Ohio ID number Box 16 - Ohio wages, tips, etc. Box 17 - Ohio income tax
1.
2.
3.
4.
5.
6.
7.
2021 Schedule of Ohio
Withholding
Sequence No. 11
Primary taxpayer’s SSN
Use only black ink/UPPERCASE letters.
21350106
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
Total
distribution
Box 1 - Gross distribution
P/S Payer’s TIN
Box 15 - Payer’s Ohio number Box 4 - Federal income tax withheld Box 14 - Ohio tax withheld
Part C - 1099-Rs
Box 4 - Federal income tax withheldBox 1 - Reportable winnings
P/S Payer’s federal ID number
Box 13 - Ohio state ID number Box 14 - Ohio state winnings Box 15 - Ohio income tax withheld
Box 4 - Federal income tax withheldBox 1 - Nonemployee compensation
P/S Payer’s TIN
Box 6 - Payer’s Ohio number Box 7 - State income Box 5 - Ohio tax withheld
Box 4 - Federal income tax withheldBox 1 - Nonemployee compensation
P/S Payer’s TIN
Box 6 - Payer’s Ohio number Box 7 - State income Box 5 - Ohio tax withheld
Box 7 -
Distribution code
Total
distribution
Box 1 - Gross distribution
P/S Payer’s TIN
Box 15 - Payer’s Ohio number Box 4 - Federal income tax withheld Box 14 - Ohio tax withheld
Box 7 -
Distribution code
Total
distribution
Box 1 - Gross distribution
P/S Payer’s TIN
Box 15 - Payer’s Ohio number Box 4 - Federal income tax withheld Box 14 - Ohio tax withheld
Box 7 -
Distribution code
Total
distribution
Box 1 - Gross distribution
P/S Payer’s TIN
Box 15 - Payer’s Ohio number Box 4 - Federal income tax withheld Box 14 - Ohio tax withheld
Box 7 -
Distribution code
Part D - W-2Gs
Box 4 - Federal income tax withheldBox 1 - Reportable winnings
P/S Payer’s federal ID number
Box 13 - Ohio state ID number Box 14 - Ohio state winnings Box 15 - Ohio income tax withheld
Box 4 - Federal income tax withheldBox 1 - Reportable winnings
P/S Payer’s federal ID number
Box 13 - Ohio state ID number Box 14 - Ohio state winnings Box 15 - Ohio income tax withheld
Part E - 1099-NECs
Schedule of Withholding – page 2 of 2
1.
2.
3.
4.
1.
2.
3.
1.
2.
2021 Schedule of Ohio
Withholding
Sequence No. 12
Primary taxpayer’s SSN
21350206
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
.
0 0
2021 Ohio IT 40P
Include the voucher below with your payment for your ORIGINAL 2021 Ohio income tax return.
Important
• Make payment payable to: Ohio Treasurer of State
• Include the tax year and the last four digits of your SSN on the “Memo” line of your
payment.
• Do not send cash.
• Do not use this voucher to make a payment for an amended return. Use Ohio IT 40XP.
• Do not use this voucher to make a payment for a school district income tax return.
Use Ohio SD 40P for an original school district income tax return. Use Ohio SD 40XP
for an amended school district income tax return.
Electronic Payment Options
You can make your payment electronically even if you le by paper. To pay by electronic
check, credit card, or debit card, visit tax.ohio.gov/pay OR scan with your phone.
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
information. We need your Social Security number in order to administer this tax.
Cut on the dotted lines. Use only black ink.
ORIGINAL PAYMENT
2021
Taxpayer’s SSN
Spouse’s SSN
(only if joint ling)
Amount of
Payment
Taxpayer’s
last name
Use UPPERCASE letters
to print the rst three letters of
Spouse’s last name
(only if joint ling)
Tax Year
OHIO IT 40P
Original Income Tax Payment Voucher
Make payment payable to: Ohio Treasurer of State
Sending with return - Mail to: Ohio Department of Taxation,
P.O. Box 2057, Columbus, OH 43270-2057
Sending without return - Mail to: Ohio Department of Taxation,
P.O. Box 182131, Columbus, OH 43218-2131
• Do NOT send cash
• Do NOT fold, staple,
or paper clip
$
First name M.I. Last name
Spouse’s rst name (only if joint ling) M.I. Last name
Address
City, State, ZIP code
0
0
Clear Form
0
5
2
1
5
0
0
0
0
0
0
0
0
0
0
4
0
2
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Form 21000106: 2021 Ohio IT 1040 If deceased (State of Ohio)

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Completed 13 February 2022

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