Resident Registration Form - Village Of Elmwood Place

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Village of Elmwood Place
Income Tax Bureau
Resident Registration Form
*Please complete and return this form within (10) ten days to:
Village of Elmwood Place, Income Tax Bureau, 6118 Vine street, Elmwood Place, OH 45216
Resident Name __________________________________ S.S. # ______________________ Date of Birth _____________
Spouse
_____________________________________ S.S. # ______________________ Date of Birth _____________
Elmwood Address ___________________________________________ Apt # ____________, Elmwood Place, OH 45216
Do you own this property?
Yes
No -
Date _______________________
If YES, when did you purchase this property?
If you are renting, who is your landlord? Name ________________________ Address _____________________________
Mailing Address (if other than above) ______________________________________________________________________
Telephone __________ __________ - _________________ Other Phone ___________ ___________ - _______________
DATE YOU MOVED INTO ELMWOOD PLACE?
MM/DD/YY
/
/
Is the address listed going to be used as
Primary Residence
Rental Property
Business
PLEASE NOTE: If this property or a portion thereof will be used as “Rental Property”, you must contact the Clerk’s office to register
for Waste Collection Pickup.
Do you receive social security/pension/disability/welfare income?
Yes
__________________
No
if so, what?
Are you FULLY RETIRED?
Yes
No
EMPLOYMENT INFORMATION
-
I am self-employed.
YOU
SPOUSE
Full-Time Job
Part-Time Job
Temporary
Full-Time Job
Part-Time Job
Temporary
Employer Name
Employer Name
Address
Address
City, State, Zip
City, State, Zip
Occupation
Occupation
Is City Tax Withheld?
Yes
No
Unsure
Is City Tax Withheld?
Yes
No
Unsure
If Yes, What City?
If Yes, What City?
OTHER HOUSEHOLD MEMBERS – Please list all members (adult/children) living at this address.
Name
Age
Date of Birth
Employment Status
I certify that the information supplied to the Income Tax Bureau on this form is true and correct to the best of my
knowledge.
Signature ___________________________________________________
Date ________________________

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