Resident Registration Questionnaire Template - City Of Reading, Ohio - Income Tax Bureau
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1
2OFFICE USE ONLY:
ATTN: READING SCHOOL PERSONNEL
ACCOUNT# ______________
(CITY WILL ASSIGN)
THIS FORM MUST BE COMPLETED AND
SIGNED
BY
THE
CITY
OF
READING
TREASURER’S
OFFICE
BEFORE
ANY
City of Reading, Ohio
Melvin T. Gertz, Treasurer
RESIDENT CAN REGISTER THEIR CHILDREN
FOR SCHOOL
(513) 733-0300
INCOME TAX BUREAU
(513) 842-1016 Fax
__________________________________
1000 MARKET STREET
Signature
Date
READING, OHIO 45215
RESIDENT REGISTRATION QUESTIONNAIRE
PLEASE COMPLETE AND RETURN WITHIN 10 DAYS
NAME:
__________________________________
Social Security # _____/____/______ Date Of Birth: ___/___/___
SPOUSE: __________________________________
Social Security #_____/____/______ Date Of Birth: ___/___/___
(IF APPLICABLE)
ADDRESS: ________________________________________APT #_____________________________________________________
TELEPHONE# (Home)_______________ (Work)_________________ DATE MOVED INTO READING: ____/____/____
1. ARE YOU A HIGH SCHOOL STUDENT? YES___ NO___ ARE YOU A COLLEGE STUDENT? YES___ NO ___
IF YOU ARE A STUDENT AND WORKING PART-TIME COMPLETE SECTION 3 ONLY, SIGN THE BACK AND RETURN.
2. ARE YOU RETIRED AND RECEIVE A PENSION OR SOCIAL SECURITY ONLY?
___ YES ___ NO
IS SPOUSE RETIRED ON A PENSION OR SOCIAL SECURITY ONLY?
___ YES ___ NO
ARE YOU ON A DISABILITY?
___ YES ___ NO
___ SHORT-TERM ___ PERMANENT
IS SPOUSE ON A DISABILITY?
___ YES ___ NO
___ SHORT-TERM ___ PERMANENT
ARE YOU UNEMPLOYED?
___ YES ___ NO
___ YES ___ NO
ON WELFARE?
IS SPOUSE UNEMPLOYED?
___ YES ___ NO
___ YES ___ NO
ON WELFARE?
(If Answer is “NO” to Question 2 Please Complete Sections 3, 4, 5 and 6 as applies to You and Spouse)
EMPLOYMENT INFORMATION
3.
YOU
SPOUSE
A) FULL-TIME EMPLOYER: ______ _________________
A) FULL-TIME EMPLOYER: ______ _________________
ADDRESS:
__________________________________
ADDRESS:
__________________________________
CITY WHERE EMPLOYED: ______________________
CITY WHERE EMPLOYED: ______________________
OCCUPATION: ____________________________ ___
OCCUPATION: ____________________________ ___
CITY TAX WITHHELD: _________________________
CITY TAX WITHHELD: _________________________
B) PART-TIME EMPLOYER: ________________________
B) PART-TIME EMPLOYER: ________________________
ADDRESS: ____________________________________
ADDRESS: ____________________________________
CITY WHERE EMPLOYED: ______________________
CITY WHERE EMPLOYED: ______________________
OCCUPATION: ________________________________
OCCUPATION: ________________________________
CITY TAX WITHHELD: _________________________
CITY TAX WITHHELD: _________________________
C) SELF-EMPLOYED? YES ___ NO ___
C) SELF-EMPLOYED? YES ___ NO ___
NAME OF BUSINESS: ___________________________
NAME OF BUSINESS: ___________________________
FEDERAL ID NO: ______________________________
FEDERAL ID NO: ______________________________
BUSINESS ADDRESS: ___________________________
BUSINESS ADDRESS: ___________________________
BUSINESS ADDRESS: ___________________________
BUSINESS ADDRESS: ___________________________
BUSINESS PHONE ____________ CELL ____________
BUSINESS PHONE ____________ CELL ____________
NAME(S) OF OFFICERS: ________________________
NAME(S) OF OFFICERS: ________________________
_______________________________________________
_______________________________________________
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