Municipal Income Tax Individual Registration Form - Income Tax Department
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1INCOME TAX DEPARTMENT
VILLAGE OF BOLIVAR
BETH WATSON – TAX ADMINISTRATOR
109 CANAL STREET NE
P.O. BOX 204
(330) 874-3717
BOLIVAR, OH 44612
(330) 874-3713 FAX
MUNICIPAL INCOME TAX INDIVIDUAL REGISTRATION FORM
►GENERAL INFORMATION
NAME: ___________________________________________________________________SOCIAL SECURITY#_______-______-________
STREET ADDRESS: __________________________________________DAY PHONE:_______________ EVE PHONE________________
P.O.BOX #_________ CITY/STATE/ZIP: ________________________________________________________________________________
DATE YOU MOVED INTO BOLIVAR: ______________________________________________
SPOUSE’S NAME: __________________________________SOCIAL SECURITY#______-____-_____ FILE JOINTLY (circle one): YES NO
LIST ANY PERSONS (OTHER THAN SPOUSE) 18 YEARS OF AGE OR OVER WHO RESIDE AT YOUR ADDRESS:
NAME: _________________________________________________________________________________ SS#_______-_____-_______
NAME: _________________________________________________________________________________ SS#_______-_____-_______
NAME: _________________________________________________________________________________ SS#_______-_____-_______
►EMPLOYMENT INFORMATION
LIST YOUR (AND SPOUSE’S IF APPLICABLE) EMPLOYERS OR SOURCE OF TAXABLE INCOME:
NAME: _________________________________________ADDRESS________________________________________________________
PHONE: ____________ LOCAL TAX WITHHELD? YES NO IF YES, LIST MUNICIPALITIES ___________________________________
NAME: _________________________________________ADDRESS________________________________________________________
PHONE: ____________ LOCAL TAX WITHHELD? YES NO IF YES, LIST MUNICIPALITIES ___________________________________
(FOR ADDITIONAL SPACE, USE OTHER SIDE)
(
) SELF EMPLOYED (
) SELF (
) SPOUSE COMPLETE FOLLOWING INFORMATION - OCCUPATION: ______________________
BUSINESS NAME: __________________________________ADDRESS: _____________________________________________________
►RETIREMENTAND NON/UNEMPLOYMENT INFORMATION
IF YOU (AND/OR SPOUSE IF APPLICABLE) ARE UNEMPLOYED, MARK “X” BESIDE STATEMENTS WHICH BEST DESCRIBE YOUR
SITUATION.
(
) TEMPORARY UNEMPLOYMENT (
) SELF (
) SPOUSE
DATES: FROM _______________________ TO ______________________
(
) PERMANENT UNEMPLOYMENT
(
) SELF (
) SPOUSE REASON: ______________________________________________________
(
) RETIRED ON PENSION AND/OR SOCIAL SECURITY (
) SELF (
) SPOUSE
(
) FULL TIME CAREGIVER AT HOME (
) SELF (
) SPOUSE
(
) IN U.S. ARMED SERVICE FROM __________ TO __________
(
) SELF (
) SPOUSE
(
) OTHER (please specify) ______________________________________________________________________________________________
►RENTAL INCOME
DO YOU (AND/OR YOUR SPOUSE IF APPLICABLE) HAVE RENTAL INCOME FROM PROPERTIES LOCATED IN OR OUT OF THE VILLAGE OF
BOLIVAR? (circle one)
YES
NO
IF YES, LIST ADDRESSES: 1. __________________________________________________________
(IN CASE OF NON-RESIDENT, THIS APPLIES ONLY TO
2. __________________________________________________________
PROPERTIES LOCATED WITHIN THE VILLAGE ONLY)
(LIST ADDITIONAL PROPERTIES ON BACK OR SEPARATE SHEET)
I CERTIFY THE ABOVE TO BE TRUE AND ACCURATE: ________________________________________________ DATE ________________
(SIGNATURE OF PERSON PREPARING)
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