Form 75 - Individual Registration Form - Regional Income Tax Agency

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Regional Income Tax Agency
FORM
Individual Registration Form
75
If you have any questions or are unable to complete this form please contact RITA’s Registration Dept. at
(440) 526-0900 or (800) 860-7482.
Names:
Primary Social Security # ____________________________
________________________
___
____________________________
Primary First Name
Middle Initial
Last Name
Spouse’s Social Security#_____________________________
________________________
___
____________________________
Spouse’s First Name
Middle Initial
Last Name
Current Address Information:
___________
___________ _____________________________
_______
P O Box
House #
Street Name
Apt #
_________________________________
______
____________
City
State
Zip Code
RITA Municipality of Registration: ____________________________
Effective Date of this Address: ____________________________
Daytime Phone
Evening Phone # ____________________
#_____________________
Prior Address Information :
________________________________
______
City
State
Effective date of this address: ____________________________
Employment Information:
Are you employed?
Y/N
Is your Spouse Employed? Y/N
Do you own rental property and/or own a business? Y/N
Does your Spouse own rental property and/or a business? Y/N
Are you retired and/or have no taxable income? Y/N
Is your spouse retired and/or have no taxable income? Y/N

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