Common use of ORIGINAL PAYMENT Clause in Contracts

ORIGINAL PAYMENT. ✁ Cut on the dotted lines. Use only black ink. First name M.I. Last name Spouse’s first name (only if joint filing) M.I. Last name Address City, State, ZIP code • Do NOT send cash • Do NOT fold, staple, or paper clip ⏵ ⏵ P.O. Box 2057, Columbus, OH 43270-2057 Taxpayer’s SSN Spouse’s SSN (only if joint filing) ⏶, ⏶, . 0 Taxpayer’s last name Spouse’s last name (only if joint filing) P.O. Box 182131, Columbus, OH 43218-2131 402 Do not staple or paper clip.‌ 21000102 Sequence No. 1 AMENDED RETURN - Check here and include Ohio IT RE. NOL CARRYBACK - Check here and include Schedule IT NOL. Primary taxpayer's SSN (required) ✔If deceased Spouse’s SSN (if filing jointly) ✔If deceased First name ▇▇▇▇▇▇'s first name (if filing jointly) Address line ▇ (▇▇▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇) or P.O. Box ▇.▇. ▇.▇. Last name Last name Address line 2 (apartment number, suite number, etc.) City State ZIP code Ohio county (first four letters) Foreign country (if the mailing address is outside the U.S.) Foreign postal code Residency Status – Check only one for primary Resident resident Check only one for spouse (if filing jointly) Nonresident ⏵⏵ Filing Status – Check one (as reported on federal income tax return) Single, head of household or qualifying widow(er) Indicate state Married filing jointly Resident Part-year resident Nonresident ⏵⏵ Indicate state Spouse’s SSN Married filing separately Ohio Nonresident Statement – See instructions for required criteria Primary meets the five criteria for irrebuttable presumption as nonresident. Spouse meets the five criteria for irrebuttable presumption as nonresident. If someone can claim you (or your spouse if filing jointly) as a dependent, check here.

ORIGINAL PAYMENT. ✁ Cut on the dotted lines. Use only black ink. First name M.I. Last name Spouse’s first name (only if joint filing) M.I. Last name Address City, State, ZIP code • Do NOT send cash • Do NOT fold, staple, or paper clip ⏵ ⏵ P.O. Box 2057▇.▇. ▇▇▇ ▇▇▇▇, Columbus▇▇▇▇▇▇▇▇, OH 43270▇▇ ▇▇▇▇▇-2057 ▇▇▇▇ Taxpayer’s SSN Spouse’s SSN (only if joint filing) ⏶, ⏶, . 0 Taxpayer’s last name Spouse’s last name (only if joint filing) P.O. Box 182131▇.▇. ▇▇▇ ▇▇▇▇▇▇, Columbus▇▇▇▇▇▇▇▇, OH 43218▇▇ ▇▇▇▇▇-2131 ▇▇▇▇ 402 Do not staple or paper clip.‌ 21000102 Sequence No. 1 AMENDED RETURN - Check here and include Ohio IT RE. NOL CARRYBACK - Check here and include Schedule IT NOL. Primary taxpayer's SSN (required) ✔If deceased Spouse’s SSN (if filing jointly) ✔If deceased First name ▇▇▇▇▇▇'s first name (if filing jointly) Address line ▇ 1 (▇▇▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇number and street) or P.O. Box ▇.▇. ▇.▇. Last name Last name Address line 2 (apartment number, suite number, etc.) City State ZIP code Ohio county (first four letters) Foreign country (if the mailing address is outside the U.S.) Foreign postal code Residency Status – Check only one for primary Resident resident Check only one for spouse (if filing jointly) Nonresident ⏵⏵ Filing Status – Check one (as reported on federal income tax return) Single, head of household or qualifying widow(er) Indicate state Married filing jointly Resident Part-year resident Nonresident ⏵⏵ Indicate state Spouse’s SSN Married filing separately Ohio Nonresident Statement – See instructions for required criteria Primary meets the five criteria for irrebuttable presumption as nonresident. Spouse meets the five criteria for irrebuttable presumption as nonresident. If someone can claim you (or your spouse if filing jointly) as a dependent, check here.