Note: If married, amounts on each line must include total income
and deductions from both you and your spouse.
Line 1: Enter amounts from box 1 of your Form(s) W-2. Also enter
gambling winnings reported in box 1 of your Form(s) W-2G.
Line 2: Enter your retirement income reported in box 2a of your
Form(s) 1099-R. The amount in this box is the taxable amount.
Line 3: Enter your taxable interest income reported in box 1 of
your Form(s) 1099-INT. Also enter your ordinary dividends report-
ed in box 1a of your Form(s) 1099-DIV. Both of these amounts are
Line 4: Enter income from any other sources not included above
(income reported on Form(s) 1099-MISC, self-employment in-
come, business income). Do NOT include any Social Security
beneﬁ ts as they are not taxable in Ohio.
Line 6: Enter uniformed services retirement income that you
included on line 2. Also enter any taxable portion of military in-
jury relief fund amounts that you received. Uniformed services
retirement income includes amounts received as retired person-
nel pay for service in the United States Army, Navy, Air Force,
Coast Guard, or Marine Corps uniformed services or reserve, or
the National guard, or received by the surviving spouse or former
spouse of such a taxpayer under the Survivor Beneﬁ t Plan on ac-
count of such taxpayer’s death.
Line 7: Enter qualifying disability and survivorship beneﬁ ts that
you included on line 2. Disability beneﬁ ts are beneﬁ ts paid by an
employee’s disability plan paid as the result of a permanent physi-
cal or mental disability. Survivorship beneﬁ ts are beneﬁ ts paid from
a qualiﬁ ed survivorship plan as the result of the death of a covered
employee. Do not include amounts that otherwise qualify as re-
tirement or pension beneﬁ ts. Upon reaching your plan’s minimum
retirement age, the beneﬁ ts received under that plan become re-
tirement beneﬁ ts and are no longer deductible. Contact your plan
administrator if you are uncertain of the minimum retirement age
under your plan.
Line 8: Enter your unreimbursed long-term care insurance pre-
miums and unsubsidized health care insurance premiums. Unre-
imbursed long-term care insurance premiums are those that you
pay during the calendar year on your own; a company, etc. is not
paying you back. Medicare Part B is not a deduction because
Social Security is not included as taxable income. Unsubsidized
health care insurance premiums are those that are not partially
paid by someone else such as an employer or a retirement plan.
Also include on this line any out-of-pocket medical expenses you
paid during the tax year and were not reimbursed to you. Some
examples of qualifying expenses include costs for prescription
medicine and insulin; hospital costs and nursing care; copayments
for medical care; eyeglasses, hearing aids, braces, crutches and
Please read this before you complete the front of this application.