Warren City Income Tax Departmeformnt Individual Questionnaire Form printable pdf download

Warren City Income Tax Departmeformnt Individual Questionnaire Form

WARREN CITY INCOME TAX DEPARTMENT

INDIVIDUAL QUESTIONNAIRE

Please complete the following questions to the best of your ability. This information

enables our office to establish a tax account for you. If you are currently filing a

Warren City Income Tax Return, your account will be updated. If you do not have a

current tax account, one will be set up for you and additional information will

follow. Please submit within 10 days of receipt.

Name ___________________________________ SSN # _____________________________

Spouse __________________________________ SSN # _____________________________

Address _________________________________ Date Moved In ______________

_________________________________

Phone No. ___________________________________

Today’s Date _____________________

1. Did you live in Warren any time during the past 5 years? □ YES □ NO

If YES, list all addresses and applicable dates:

Date From - Date To:

_____________________________________________________________

2. Did you file a Warren City Income Tax Return last year? □ YES □ NO

3. Are you presently employed?

□ YES

□ NO

Spouse employed?

□ YES

□ NO

4. If unemployed, do you receive

□ SSI

□ ADC

□ Permanent Disability □ State Unemployment

5. Are you retired?

□ YES

□ NO

Date Retired__________

Spouse retired?

□ YES

□ NO

Date Retired__________

6. List any other Warren resident living in your home over the age of 16 years old who

has earned income.

Name_____________________________ SSN ________________

PLEASE COMPLETE REVERSE SIDE

Warren City Income Tax Departmeformnt Individual Questionnaire Form