Individual Questionnaire - City Of Hamilton Page 2
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2_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Is anyone else in your household working?
Yes_____
No_____
If yes, please give the person’s name and Social Security number.
Name__________________________________________________________ Social Security No._____________________________
If you or any member of your household listed above pay city income taxes through their employer, you must include a copy of a recent
paystub or W-2 when returning this form.
If you own rental property, give locations of the property.
Give date each rental property
Gross rent received per month
(If more space is required, use additional sheet).
was acquired
from rental of each property
1.
$
2.
$
3.
$
If you are currently serving in the U.S. Armed Forces, please check here.
_____
If you rent, please list name and address of landlord. ___________________________________________________________________________
_____________________________________________________________________________________________________________________
If you are unemployed, mark “X” on the line(s) before the statement which most accurately describes your current situation.
_____ Temporarily Unemployed
_____ Retired, Pension or Social Security
_____ Welfare or ADC
_____ Other (Please Specify Below)
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Signature ______________________________________________________________
Date ________________________________________
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