Individual Income Tax Questionnaire Form Ohio

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THE CITY OF SPRINGFIELD
INCOME TAX DIVISION
OFFICE HOURS
STATE OF OHIO
CITY HALL
8 AM to 5 PM
P O Box 5200
Monday through Friday
76 E High Street
Phone 937/324-7357
Springfield, OH 45501
Fax 937/328-3471
INDIVIDUAL - INCOME TAX QUESTIONNAIRE
Springfield has a mandatory filing requirement for all residents. Therefore, each resident will be set up as a separate
account.
Acct. #:____________
Acct:#_______________
Please Type or Print:
(Office Use Only)
(Office Use Only)
Taxpayer #1 _______________________________Social Security ______/_____/_______ DOB:
Home Telephone #: (______) ________________________ Work Telephone #: (______)
Taxpayer #2 (Spouse)_______________________ Social Security _____/____/_______ DOB:
Home Telephone #: (______) ________________________ Work Telephone #: (______)
Email Address
Current Address ______________________________________ City ___________________State ____ Zip
Date Moved to Current Address: _____/____/______
Former Addresses
1. _________________________________ City ________________ State _____ Date in _________ Date out
2. _________________________________ City ________________ State _____ Date in _________ Date out
Please list all residences within the City of Springfield in addition to the 2 most recent addresses.
Taxpayer #1 Employer:
Employer Address
Date began employment __________________________Date terminated employment
Does employer withhold city tax? No ____ Yes ____, for the City of
Taxpayer #2 (Spouse) Employer:
Employer Address
Date began employment __________________________Date terminated employment
Does employer withhold city tax? No ____ Yes ____, for the City of
Self-Employed:
Business Name ___________________________________________________ Type of Business
Business Address _________________________________________________ Date Business started
Do you have employees? No ____ Yes ____, If YES, your Federal ID#
Do you own Rental Property? No ____ Yes ____ If Yes, continue below.
Location of property [actual address(es)]:
Date acquired and/or date first rented:
Use back of form for additional listings.
Other Income, e.g. partnerships, commissions, fees, etc. List types:
Names and Social Security Numbers of other members of the household over age 18:
___________________________________________________SSN: ______/_____/________ DOB:
___________________________________________________SSN: ______/_____/________ DOB:
___________________________________________________SSN: ______/_____/________ DOB:
If you are not liable for city tax, give reason:
Active Duty Military income and some types of retirement income are not taxable. You may still be required to file a Return.
Signed _________________________________________________________________ Date
Rev 09/15

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