Individual Questionnaire Form - City Of Fairfield Income Tax Division

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City of Fairfield
INDIVIDUAL QUESTIONNAIRE
Please assist us in completing your account information. If you should have any questions while completing this form,
please contact our office. Thank you for your cooperation.
Taxpayer Information
Taxpayer Name: _______________________________
Social Security Number _____-_____-_______
Address: ____________________________________________________________________________
Home Phone Number (____) _____-_______
Mobile Phone Number (____) _____-_______
Type of Income (Please check all that apply):
____ Employed
____ Self-Employed
____ Rental Property Owner ____ Retired
____ Disabled
Name of Employer: ____________________________________________________________________
Address of Employer: __________________________________________________________________
Is local tax being withheld? (Please check one): ____ Yes, name of City ____________________
____ No
Date moved into Fairfield: ____________
Do you (Please check one): ____ Own
____ Rent
____ Lease
If you rent or lease, what is the name and address of your landlord? ___________________________
__________________________________________________________________________________
Date began business in Fairfield (for Schedule C filers): ____________
Date purchased rental property and location (for Schedule E filers): ___________________________
Spouse Information
Spouse’s Name: ______________________________
Social Security Number _____-_____-_______
Address: ____________________________________________________________________________
Home Phone Number (____) _____-_______
Mobile Phone Number (____) _____-_______
Type of Income (Please check all that apply):
____ Employed
____ Self-Employed
____ Rental Property Owner ____ Retired
____ Disabled
Name of Spouse’s Employer: ____________________________________________________________
Address of Spouse’s Employer: __________________________________________________________
Is local tax being withheld? (Please check one): ____ Yes, name of City ____________________
____ No
Date moved into Fairfield: ____________
Do you (Please check one): ____ Own
____ Rent
____ Lease
If you rent or lease, what is the name and address of your landlord? ___________________________
__________________________________________________________________________________
Date began business in Fairfield (for Schedule C filers): ____________
Date purchased rental property and location (for Schedule E filers): ___________________________
INCOME TAX DIVISION
701 Wessel Dr, Fairfield, Ohio 45014 Phone 513-867-5327 Fax 513-867-5333

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