Income Tax Form Individual Questionnaire - City Of Wapakoneta printable pdf download

Income Tax Form Individual Questionnaire - City Of Wapakoneta

CITY OF WAPAKONETA

INCOME TAX DEPARTMENT

701 PARLETTE COURT

P O BOX 269

WAPAKONETA, OHIO 45895

(419) 738-7342 Phone

(419) 738-4762 Fax

INDIVIDUAL QUESTIONNAIRE

Please complete this questionnaire and return it to the Income Tax Department. Information provided will be

used exclusively for income tax purposes and will not be further disclosed.

Name __________________________________________ SS# ____________________________________

Spouse _________________________________________ SS# ____________________________________

Address _________________________________________________________________________________

Date you became a resident or property owner ___________________________________________________

List anyone else who is employed and living in the household

Name ___________________________________ SS# _____________________________________

Name of your employer _____________________________________________________________________

Spouse’s employer _________________________________________________________________________

Is your total income derived from salaries and wages: [ ] Yes [ ] No

If no, please list other sources of income: _______________________________________________________

If you are not presently employed, place an “X” after the listing below which most accurately describes your

status.

[ ] Retired

Dated retired ___________________

[ ] Unemployed

[ ] Military

Date entered ___________________

[ ] Government assistance

[ ] Other

Specify ________________________________________________________________

Signature __________________________________________

Date _______________________________

Income Tax Form Individual Questionnaire - City Of Wapakoneta