NOTICE OF QUARTERLY PAYMENT ON

DECLARATION OF ESTIMATED INCOME TAX

Name of Municipality ________________________

Form Q-1

ESTIMATE

PAYMENT

UNPAID BALANCE

MAKE CHECKS PAYABLE TO THE MUNICIPALITY FOR WHICH YOU ARE FILING.

Name and Address: Amount Enclosed:_________________

_______________________________________

_______________________________________

_______________________________________

MAIL TO: DEPARTMENT OF TAXATION

106 E. SPRING STREET

ST. MARYS, OHIO 45885