Individual Registration Form Municipal Income Tax

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City of Green
Division of Taxation
PO BOX 460
GREEN OH 44232-0460
PHONE: 330 896-6622
FAX 330 896-6927
Email:
Website:
INDIVIDUAL REGISTRATION FORM
MUNICIPAL INCOME TAX
PLEASE RETURN THIS REGISTRATION TO THE ADDRESS ABOVE
SOCIAL SECURITY NO. ________________ SPOUSE S.S. NO. _____________________
HEAD OF HOUSEHOLD_________________________ PHONE NO. _________________
SPOUSE ___________________________________________________________________
STREET ADDRESS__________________________________________________________
CITY_____________________________STATE______________ ZIP__________________
DATE MOVED INTO GREEN_________________________________________________
EMPLOYMENT (GIVE NAME AND ADDRESS OF EMPLOYERS) INDICATE WHETHER
FOR YOURSELF OR SPOUSE
NAME
ADDRESS/CITY
CHECK ONE
__________________________ ____________________
SELF___ SPOUSE ___
__________________________ ____________________
SELF___ SPOUSE ___
__________________________ ____________________
SELF___ SPOUSE___
__________________________ ____________________
SELF___ SPOUSE___
CHECK OTHER SOURCES OF INCOME: RENT__ PENSION__ SELF EMPLOYED___
TRADE NAME AND ADDRESS IF SELF EMPLOYED___________________________
OTHER (PLEASE SPECIFY) _________________________________________________
LIST ALL OTHER RESIDENTS IN HOUSEHOLD (AGE 18 OR OVER)
NAME
AGE
SOCIAL SECURITY NO
___________________________
_____
________________________________
___________________________
_____
________________________________
___________________________
_____
________________________________
___________________________
_____
________________________________
___________________________
_____
________________________________
SIGNATURE_____________________________ DATE___________________________

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