Form Tx-3001b-Tj - Individual Tax Questionnaire printable pdf download

Form Tx-3001b-Tj - Individual Tax Questionnaire

IVISION

NDIVIDUAL

UESTIONNAIRE

_______________________

ATE

AILED

Please complete the following and return to the City of Kettering - Tax Division, P.O. Box 293100, Kettering, Ohio

45429, within 15 days from the date mailed.

Name

Taxpayer’s Social Security No.

Spouse’s Name

Spouse’s Social Security No.

Address

City

State

Zip

Date moved to Kettering

Old Address

Date moved from Kettering

Name/address of your employer(s)

Is employer withholding city tax? Yes ______

No ______

For what city?

Name/address of spouse’s employer(s)

Is employer withholding city tax? Yes ______

No ______

For what city?

If self-employed:

Business name/address

Nature of business

Federal I.D. number (if applicable)

Do you have employees? Yes ______

No ______

Are you withholding city tax? Yes ______ No ______

What city (cities) do you work in?

Do you work in a locale other than where your employer is located? Yes ______ No ______

Location of work

Does your spouse? Yes ______

No ______

Location of work

(Over)

tx-3001b-tj.doc (Rev. 12/7/01)

Form Tx-3001b-Tj - Individual Tax Questionnaire