Individual Questionnaire Form - City Of Canfield Income Tax Department

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INDIVIDUAL QUESTIONNAIRE
CITY OF CANFIELD INCOME TAX DEPARTMENT, 104 LISBON STREET, CANFIELD, OHIO 44406-1416
Phone: 330-533-1101 ~ Fax: 330-533-2668 ~ Web-site:
~ E-mail:
vshook@ci.canfield.oh.us
Name:
Address:
Date:
Per Ordinance 183.03 the imposition of one percent tax on all salaries, gross wages, commissions, tips, gratuities, and other
compensation earned by resident or non-resident. To establish and maintain accurate records, the Income Tax Ordinance requires that
you complete and return this form within ten days.
FAILURE TO COMPLY WITH THE REQUIREMENTS OF PROVIDING THIS INFORMATION TO THE CITY AS REQUIRED CODIFIED
ORDINANCE 183.03 IS A VIOLATION OF THE LAW PUNISHABLE BY A FINE OF UP TO $1,000.00 PER ORDINANCE 183.99. IF
REQUESTED INFORMATION IS NOT RECEIVEVED, YOU WILL BE SUMMONED TO MAYOR’S COURT.
SELF:
SPOUSE:
1. Name __________________________________________
Name ___________________________________________
2. Street Address _________________________________________ Street Address_______________________________________
3. Soc. Sec. # ________________________________________
Soc. Sec. # _______________________________________
4. D.O.B. ___________________________________________
D.O.B. ___________________________________________
5. Employer(s) _______________________________________
Employer(s) _______________________________________
6. Occupation ________________________________________
Occupation _______________________________________
7. Self-employed: Name & address of business
Self-employed: Name & address of business
____________________________________________________
________________________________________________
____________________________________________________
________________________________________________
8. Date moved to City __________________________________
Date moved to City _________________________________
9. If moved out give date ________________________________
If moved out give date _______________________________
10. Home phone # ______________________________________
Home phone # _____________________________________
11. Cell phone # ________________________________________
Cell phone # _______________________________________
12. Work phone # ______________________________________
Work phone # ______________________________________
13. If either of you is not employed, explain (i.e. student, under age 18. retired, or disabled), and give date of retirement or disability, etc.:
_______________________________________________________________________________________________________
14. If you or spouse have any other source(s) of income (commissions, rental, farm, business, partnership, etc.) list them:
_______________________________________________________________________________________________________
15. Have you ever filed a Canfield Tax Return? ____ 16. Prior address ________________________________________________
17. List other individuals 18 and over that reside with you. Use back if necessary.
NAME ___________________________________________________
SOC. SEC. # ______________________________
NAME ___________________________________________________
SOC. SEC. # ______________________________
18. If renting, give name, complete address, and phone number of landlord: _____________________________________________
______________________________________________________________________________________________________
19. ________________________________________________
20. ________________________________________________
Your Signature
Date
Spouse’s Signature
Date

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