City Of Brook Park Individual Questionnaire Form

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CITY OF BROOK PARK INDIVIDUAL QUESTIONNAIRE
1. NAME __________________________________________________________________________
FIRST, MIDDLE, LAST
2. SPOUSE’S FIRST NAME AND MIDDLE INITIAL___________________________________________
3. YOUR BIRTHDATE_________________ SPOUSE’S BIRTHDATE_____________________________
4. ADDRESS____________________________________________________________________________
5. NUMBER OF YEARS AT THIS ADDRESS_________ IF APPLICABLE DATE RETIRED__________
6. YOUR SS#________________________SPOUSE’S SS#_______________________________________
7. TELEPHONE NO.__________________MOVE IN OR MOVE OUT DATE_______________________
8. IF YOU HAVE FILED A BROOK PARK TAX RETURN BEFORE, UNDER WHAT
NAME____________________________ ADDRESS__________________________________________
ACCOUNT NO. (IF KNOWN)____________________
9. NAME & ADDRESS OF PRESENT EMPLOYER____________________________________________
SPOUSE’S EMPLOYER_________________________________________________________________
DO PRESENT EMPLOYERS WITHHOLD CITY INCOME TAX?______YES______NO
10. DO YOU OR YOUR SPOUSE HAVE INCOME FROM SELF-EMPLOYMENT OR RENTAL
PROPERTY _______YES________NO
IS YOUR RENTAL INCOME IN EXCESS OF $125.00 PER MONTH_______YES_______NO
10A. NAME OF BROOK PARK TENANTS:________________________________________________
11. DO YOU RENT YOUR PLACE OF RESIDENCE?_______ IF YES INDICATE AN ADDRESS OF
THE OWNER OF YOUR RENTAL PROPERTY_________________________________________
12. DOES ANY OTHER EMPLOYED PERSON RESIDE AT YOUR ADDRESS_________IF YES
LIST PERSON/S NAME, SS#, AGE AND PLACE OF EMPLOYMENT______________________
_________________________________________________________________________________
13. ADDITIONAL HOUSEHOLD MEMBERS
NAME
RELATIONSHIP
SS#
DATE OF BIRTH
1. __________________________ _____________________ ______________ _______________________
2. __________________________ _____________________ ______________ _______________________
3. __________________________ _____________________ ______________ _______________________
4. __________________________ _____________________ ______________ _______________________
I HEREBY CERTIFY THAT ALL INFORMATION AND STATEMENTS HEREIN ARE TRUE AND
CORRECT.
SIGNATURE________________________________ DATE___________________________________
ALL INFORMATION PROVIDED ON THIS FORM IS CONFIDENTIAL AND USED FOR CITY INCOME
TAX PURPOSES ONLY.
PLEASE SIGN AND DATE THIS DOCUMENT:
City of Brook Park
Fax (216) 433-0822
SUBMIT VIA REGULAR MAIL, FAX,
Tax Dept.
OR THE GREEN DEPOSITORY BOX
6161 Engle Rd
OUTSIDE CITY HALL
Brook Park, OH 44142
FAILURE TO RETURN A COMPLETED FORM WILL SUBJECT YOU TO A MINIMUM $25
PENALITY. (CHAPTER 1705.03 DUTY TO REGISTER)

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