Individual Questionnnaire Form Oregon

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CITY OF OREGON - DEPARTMENT OF TAXATION
5330 SEAMAN ROAD OREGON, OH 43616-2608
419-698-7034
INDIVIDUAL Questionnaire
NAME : ____________________________________
SOCIAL SECURITY # : __________________
ADDRESS : __________________________________
SPOUSE : _____________________________
__________________________________
__________________________________
SPOUSE S.S.# : _________________________
__________________________________
__________________________________
PHONE : ______________________________
The City of Oregon levies an Income Tax at the rate of 2.25% on all salaries, wages, net earnings from business
activities, and other compensation earned by its residents. This tax equally applies to non-residents to the
extent that they are engaged in business activities within the City. Information requested here is necessary to
establish your income tax account and shall be held in strict confidence as stated in Ordinance No. 120-1969.
You are to complete all portions of this form. FAILURE TO COMPLY WITH THIS REQUEST MAY
RESULT IN CRIMINAL PROSECUTION!
Should you have difficulty answering any questions appearing on this form, or feel this form does not apply to
you, please phone our office at 698-7034 for clarification. This form must be completed, signed and
returned within 10 days.
1. Do you own the property listed above? ______ Yes ______ No
If no, state name and address of landlord: ___________________________________________________
_____________________________________________________________________________________
2. Date that you moved into the City of Oregon: ________________________________________________
Date that you moved out of the City of Oregon if applicable: ____________________________________
3. State your previous address: ______________________________________________________________
4. Are you presently employed? ______ Yes ______ No
If yes, is this your first year to be employed while an Oregon resident? ______ Yes ______ No
If yes, state the name and address of your employer: __________________________________________
_____________________________________________________________________________________
5. Do you have other income or are you engaged in any other business activity? ______ Yes ______ No
6. Do any other individuals with taxable income reside at this address: ______ Yes ______ No
If yes, state name and relationship _________________________________________________________
7. I certify the above to be true and accurate: _______________________________
________________
Signature
Date
IT IS MANDATORY THAT ALL INDIVIDUALS RESIDING IN OREGON AND
HAVING TAXABLE INCOME FILE A CITY RETURN!

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