Individual Questionnaire Form - Ohio Income Tax Division
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1B A R C O D E
L A B E L
INDIVIDUAL QUESTIONNAIRE
INCOME TAX DIVISION
1 Cascade Plaza - 11th Floor
Akron, OH 44308 -1100
(330) 375-2290
Fax (330) 375-2112
The following information is necessary for us to update your income tax records with the City of Akron.
If additional space is
needed, use the back of this form.
PLEASE COMPLETE AND RETURN THIS QUESTIONNAIRE WITHIN TEN (10) DAYS.
TAX OFFICE USE ONLY
Date issued ______________________________
Agent/Auditor _____________________________
Account No. ______________________________
Akron Dist ____________
Ind Code__________
NAME ____________________________________________________________________________
SOC SEC #_____________________________
ADDRESS ___________________________________________________________________________________________________________________
OCCUPATION________________________________________ BIRTHDATE (YR)_____
DAYTIME PHONE _________________________________
SPOUSE’S NAME____________________________________________________________________ SOC SEC # ____________________________
If you have filed a City of Akron Income Tax Return before, under what name and Akron tax account number did you file?
NAME USED ________________________________________________________________________
Account # ______________________________
List your employment history including SELF-EMPLOYMENT, UNEMPLOYMENT, SCHOOL, etc., for the past 6 years.
(If SELF-EMPLOYED write “SELF” below, along with the dates “FROM” and “TO”, and complete the table below.)
WAS CITY
FOR
DATES
EMPLOYER’S NAME
ADDRESS WHERE YOU WORKED
TAX
WHICH
WITHHELD?
CITY?
FROM
TO
If SELF-EMPLOYED in the past 6 years, complete the following table.
HAVE YOU HAD
BUSINESS NAME
BUSINESS ADDRESS
TYPE OF BUSINESS
EMPLOYEES?
List all of your FORMER ADDRESSES and DATES OF RESIDENCY for the past 6 years.
FROM
TO
STREET
CITY
STATE
Do you own rental property in Akron?
YES_____
NO _____
(If yes, we will send you a rental questionnaire upon receipt of this form.)
Under penalties of perjury, I certify that all information and statements herein are true and correct.
Signature ___________________________________________________________ DATE__________________________
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