Form SD 101 Short Fillable Employer's Payment of School District Income Tax Withheld
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

(Fairfi eld) 0175 (Pay this amount) (Reset Form) Reset Form (Sandusky Seneca) 0100 1% Morrow Union) 0100 1% (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) (text) 0502 Athens CSD (Athens) 0100 1% 7401 Bettsville LSD (Seneca) 0100 1% 07080102 0908 Ross LSD (Butler) 0075 p% 8602 Edgerton LSD (Defi ance Williams) 0100 1% 1204 Northwestern LSD (Clark Champaign) 0100 1% 6803 Eaton CSD (Preble) 0150 12% 1704 Crestline EVSD (Crawford Richland) 0025 4% 2502 Canal Winchester LSD (Fairfield 1901 Ansonia LSD (Darke) 0175 1p% 7202 Fremont CSD (Sandusky) 0125 14% 1902 Arcanum Butler LSD (Darke) 0150 12% 2904 Greeneview LSD (Clinton Fayette 2001 Ayersville LSD (Defi ance) 0100 1% 1904 Greenville CSD (Darke) 0050 2% 2004 Hicksville EVSD (Defi ance) 0150 12% 8708 Perrysburg EVSD (Wood) 0050 2% 2301 Amanda Clearcreek LSD (Fairfi eld) 0150 12% 2302 Berne Union LSD (Fairfi eld Hocking) 0100 1% 2305 Lancaster CSD (Fairfi eld) 0150 12% 1703 Colonel Crawford LSD (Crawford) 0125 14% 2801 Berkshire LSD (Geauga) 0100 1% 2501 Bexley CSD (Franklin) 0075 p% 2805 Ledgemont LSD (Ashtabula Geauga) 0125 14% 1502 Columbiana EVSD (Columbiana 3201 Arcadia LSD (Hancock Seneca) 0100 1% 1305 Goshen LSD (Clermont Warren) 0100 1% 3202 Arlington LSD (Hancock) 0125 14% Greene) 0100 1% 3301 Ada EVSD (Hancock Hardin) 0075 p% 5406 Fort Recovery LSD (Darke Mercer) 0150 12% 3501 Holgate LSD (Henry) 0150 12% 5507 Piqua CSD (Miami) 0125 14% 3603 Greenfield EVSD (Fayette Highland 8301 Carlisle LSD (Montgomery Warren) 0100 1% 3604 Hillsboro CSD (Highland) 0100 1% 2307 Pickerington LSD (Fairfi eld Franklin) 0100 1% 3901 Bellevue CSD (Erie Huron Sandusky 3902 Monroeville LSD (Erie Huron) 0150 12% 3203 Cory Rawson LSD (Hancock) 0175 1p% 3907 Willard CSD (Crawford Huron) 0075 p% Perry) 0200 2% 43218 2388 4508 North Fork LSD (Knox Licking) 0100 1% 8502 Dalton LSD (Wayne) 0075 p% 4901 Jefferson LSD (Madison) 0050 2% 1303 Clermont Northeastern LSD (Brown 4902 Jonathan Alder LSD (Franklin Madison Clermont) 0100 1% 5008 Sebring LSD (Mahoning) 0100 1% 8703 Elmwood LSD (Hancock Wood) 0125 14% 5101 Elgin LSD (Delaware Hardin Marion) 0075 p% 8801 Carey EVSD (Seneca Wyandot) 0100 1% 5204 Cloverleaf LSD (Medina) 0050 2% Richland Seneca) 0150 12% 5401 Celina CSD (Mercer) 0075 p% 0203 Bluffton EVSD (Allen Hancock) 0050 2% 5501 Bethel LSD (Miami) 0075 p% 2101 Big Walnut LSD (Delaware) 0075 p% 5504 Miami East LSD (Champaign Miami) 0175 1p% 6901 Columbus Grove LSD (Allen Putnam) 0100 1% 5505 Milton Union EVSD (Miami) 0125 14% 6902 Continental LSD (Putnam) 0100 1% 5509 Troy CSD (Miami) 0150 12% 2304 Fairfield Union LSD (Fairfi eld Hocking 5902 Highland LSD (Delaware Morrow) 0050 2% 2604 Pettisville LSD (Fulton Henry) 0100 1% 5903 Mount Gilead EVSD (Morrow) 0075 p% 1510 United LSD (Columbiana) 0050 2% 6301 Antwerp LSD (Paulding) 0150 12% 2603 Gorham Fayette LSD (Fulton) 0100 1% 6501 Circleville CSD (Pickaway) 0075 p% 5502 Bradford EVSD (Darke Miami Shelby) 0175 1p% 6502 Logan Elm LSD (Hocking Pickaway) 0100 1% Mahoning) 0100 1% 7001 Clear Fork Valley LSD (Knox 7201 Clyde Green Springs EVSD2102 Buckeye Valley LSD (Delaware Marion 7403 Hopewell Loudon LSD (Seneca) 0050 2% 4201 Centerburg LSD (Delaware Knox 7501 Anna LSD (Shelby) 0125 14% 1903 Franklin Monroe LSD (Darke Miami) 0075 p% 7502 Botkins LSD (Auglaize Shelby) 0125 14% 2303 Bloom Carroll LSD (Fairfi eld) 0125 14% 7506 Jackson Center LSD (Auglaize Licking) 0075 p% 7612 Northwest LSD (Stark Summit 4202 Danville LSD (Holmes Knox) 0175 1p% 8501 Chippewa LSD (Wayne) 0100 1% 8701 Bowling Green CSD (Henry Wood) 0050 2% 8605 Montpelier EVSD (Williams) 0125 14% 5503 Covington EVSD (Miami) 0175 1p% 8702 Eastwood LSD (Wood) 0100 1% Franklin) 0075 p% 8705 North Baltimore LSD (Hancock 1503 Crestview LSD (Columbiana) 0100 1% and mail to: Ohio Department of Taxation Auglaize Logan) 0100 Boldface indicates a newly enacted rate a rate change for 2013 or a change in the tax type Bryan CSD (Williams) 0100 Buckeye Central LSD (Crawford Huron Decimal Decimal District Income Tax Withheld Do NOT fold check or voucher Do not send cash Make remittance Do not staple or otherwise attach yourcheck or check stub to this coupon Earned Income Only Tax Base School Districts Traditional Tax Base School Districts (cont d ) Employer s Payment of Employer s Payment of School Evergreen LSD (Fulton Lucas) 0200 Fairbanks LSD (Madison Union) 0100 Fairborn CSD (Clark Greene Fairlawn LSD (Shelby) 0075 For State Use Only For the Period Ending Fort Loramie LSD (Darke Shelby) 0150 Go paperless! File your return through Ohio Business Gateway: tax ohio gov Hardin Houston LSD (Shelby) 0075 Hardin Logan) 0050 Hardin Northern LSD (Hancock Hardin) 0175 Holmes Knox Richland) 0125 I declare under penalties of perjury that this return including any accompanyingschedules and statements has been examined by me and to the best of myknowledge and belief is a true correct and complete return and report Jennings LSD (Putnam) 0075 Johnstown Monroe LSD (Delaware Kalida LSD (Putnam) 0100 Kenton CSD (Hardin Wyandot) 0150 Lakota LSD (Sandusky Seneca Wood) 0150 Leipsic LSD (Putnam) 0075 Liberty Benton LSD (Hancock) 0075 Liberty Center LSD (Fulton Henry) 0175 Liberty Union Thurston LSD Licking Valley LSD (Licking Muskingum) 0100 Licking) 0050 Licking) 0075 Licking) 0100 Logan Shelby) 0100 1% 2002 Central LSD (Defi ance Williams) 0075 p% Logan) 0150 London CSD (Madison) 0100 Lorain) 0100 Loudonville Perrysville EVSD (Ashland M D D YM Y Madison LSD (Butler) 0050 Madison) 0150 Marion Wyandot) 0125 McComb LSD (Hancock Putnam Mechanicsburg EVSD (Champaign Millcreek West Unity LSD (Williams) 0100 Miller City New Cleveland LSD (Putnam) 0125 Minster LSD (Auglaize Darke Mercer Mississinawa Valley LSD (Darke) 0175 Mohawk LSD (Crawford Seneca Montgomery Preble) 0175 Montgomery) 0050 National Trail LSD (Darke Preble) 0175 New Bremen LSD (Auglaize Mercer New Knoxville LSD (Auglaize Shelby) 0125 New Lebanon LSD (Montgomery) 0125 New London LSD (Ashland Huron New Miami LSD (Butler) 0100 New Riegel LSD (Seneca) 0150 Newark CSD (Licking) 0100 Newton LSD (Darke Miami) 0175 North Union LSD (Delaware Union) 0100 Northmor LSD (Marion Morrow Northwestern LSD (Ashland Wayne) 0125 Norwalk CSD (Huron) 0050 Oberlin CSD (Lorain) 0200 OHIO SD 101 Short Ohio Withholding Acct No Payment Due Date Old Fort LSD (Sandusky Seneca) 0100 One check only Otsego LSD (Henry Lucas Wood) 0100 Ottawa Glandorf LSD (Putnam) 0050 Ottoville LSD (Paulding Putnam) 0075 P O Box 182388 Columbus OH Pandora Gilboa LSD (Allen Putnam) 0175 Parkway LSD (Auglaize Mercer Patrick Henry LSD (Henry Putnam Paulding EVSD (Paulding Putnam) 0100 payable to School District Income Tax Pickaway) 0150 Please cut on the dotted lines DO NOT USE PENCIL to complete this form Plymouth Shiloh LSD (Crawford Huron Preble Shawnee LSD (Butler Rev 12/12 Rev 9/08 Reynoldsburg CSD (Fairfi eld Franklin Richland) 0100 Richland) 0100 1% Ridgemont LSD (Hardin Logan) 0175 Riverdale LSD (Hancock Hardin Riverside LSD (Logan Shelby) 0200 Ross) 0125 14% 2902 Cedar Cliff LSD (Clark Greene) 0125 14% Russia LSD (Darke Shelby) 0075 School District Income Tax School District Name School Districts With an Income Tax for 2013 SD 101 SD Number SD# School District Name (and Counties) Rate Percent SD# School District Name (and Counties) Rate Percent Seneca East LSD (Huron Seneca) 0100 Seneca) 0050 2% (continued on next page) Shelby CSD (Richland) 0100 Shelby) 0100 Signature Date South Central LSD (Huron Richland) 0125 Southeastern LSD (Clark Greene) 0100 Southwest Licking LSD (Fairfield Southwest LSD (Hamilton Butler) 0075 Spencerville LSD (Allen Auglaize Springfield LSD (Mahoning) 0100 Stryker LSD (Williams) 0150 Swanton LSD (Fulton Lucas) 0075 Talawanda CSD (Butler Preble) 0100 Tax Due Taxable Year Teays Valley LSD (Fairfi eld Franklin Total Tax Due Traditional Tax Base School Districts Traditional Tax Base School Districts (cont d ) Traditional Tax Base School Districts (cont d ) Tri Village LSD (Darke) 0150 Triad LSD (Champaign Logan Union) 0150 Triway LSD (Holmes Wayne) 0075 Twin Valley Community LSD (Preble) 0075 Union Scioto LSD (Ross) 0050 Union) 0075 p% 5402 Coldwater EVSD (Mercer) 0050 2% Upper Sandusky EVSD (Crawford Upper Scioto Valley LSD (Auglaize Use Ohio form SD 101 short when reporting nine or fewer school districts for a period Valley View LSD (Montgomery Preble) 0125 Van Wert CSD (Van Wert) 0100 Van Wert) 0100 Van Wert) 0125 Vanlue LSD (Hancock Seneca Versailles EVSD (Darke Shelby) 0100 Walnut Township LSD (Fairfield) 0125 Wapakoneta CSD (Auglaize) 0075 Warren) 0050 Wayne Trace LSD (Paulding Putnam Wayne) 0100 1% 2003 Defiance CSD (Defi ance Paulding) 0050 2% Waynesfield Goshen LSD (Allen Wellington EVSD (Huron Lorain) 0100 West Liberty Salem LSD (Champaign Western Reserve LSD (Erie Huron) 0125 When reporting 10 or more school districts you must use Ohio form SD 101 long Wilmington CSD (Clinton Greene) 0100 Withheld Wood) 0125 14% 8101 Crestview LSD (Van Wert) 0100 1% Wood) 0150 Wood) 0175 Wyandot) 0100 Wyandot) 0100 Wyoming CSD (Hamilton) 0125 Xenia Community CSD (Greene Yellow Springs EVSD (Clark Greene) 0100