Form Tx-3001b-Tj - Individual Tax Questionnaire Page 2

If you have income other than salary, wages or self-employment, please complete the following:

Do you own rental property?

Yes ______

No ______

Do you have gross rental receipts (income before expenses) in excess of $100 per month? Yes ____ No ___

List address(es) of rental(s)

Other income, e.g., partnerships, estates, trusts, miscellaneous, etc.

Are you currently filing a city income tax return?

Yes ______

No ______

What city?

Did you file a City of Kettering Income Tax Return last year? Yes ______

No ______

Have you been audited by the Internal Revenue Service within the last three years? Yes ______ No ______

If yes, what tax years?

10.

If you are not liable for City of Kettering tax, state reason below, sign the questionnaire and return the form

to the City of Kettering Tax Division. Reason(s):

Date

Taxpayer’s Signature

Spouse’s Signature

Phone (home)

Phone (work)

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

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Parent category: Financial