Questionnaire Form
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1QUESTIONNAIRE
CITY OF PARMA HEIGHTS
FINANCE DEPARTMENT – TAX DEPARTMENT
6281 Pearl Road, Parma Heights, Ohio 44130
Please Print or Type
Filing as: INDIVIDUAL _____ JOINT _____
1.
NAME:___________________________________________________________ BIRTHDATE: __________________SOC. SEC. NO: __________________________
First
Mi
Last
SPOUSE’S
2.
NAME: ___________________________________________________________BIRTHDATE:: _________________ SOC. SEC. NO.: _________________________
First
Mi
Last
3.
ADDRESS:_____________________________________________________________________________________
SUITE NO: _____________________________
4.
PHONE NO: (
) ___________________________________ DATE MOVED INTO PARMA HEIGHTS _________________________________________
DATE MOVED OUT OF PARMA HEIGHTS __________________________________________
5.
EMAIL ADDRESS ________________________________________________________________________________________________________________________
6.
GIVE NAME, BIRTHDATE, AND SOCIAL SECURITY # OF ALL CHILDREN AND OTHERS RESIDING AT THIS ADDRESS:
NAME
BIRTHDATE
SSN
NAME
BIRTHDATE
SSN
7.
EMPLOYER:____________________________________________________ SPOUSES EMPLOYER: __________________________________________________
8.
IF YOU OR YOUR SPOUSE ARE NOT EMPLOYED, MARK AN “X” IN FRONT OF THE STATEMENT WHICH MOST ACCURATELY APPLIES:
STATUS THAT APPLIES TO NAME ON LINE 1
______ RETIRED SINCE _______________________________ ______ TEMPORARILY UNEMPLOYED SINCE _________________________
______ DISABLED SINCE ______________________________ ______ IN ARMED SERVIES SINCE ___________________________________
______ OTHER ____________________________________________________________________________________________________________________
STATUS THAT APPLIES TO NAME ON LINE 2
______ RETIRED SINCE _______________________________
______ TEMPORARILY UNEMPLOYED SINCE ________________________
______ DISABLED SINCE ______________________________ ______ IN ARMED SERVIES SINCE __________________________________
______ OTHER ___________________________________________________________________________________________________________________
9.
DO YOU OR YOUR SPOUSE HAVE INCOME FROM SELF-EMPLOYMENT?
________________ YES
___________________ NO
IF YES, NAME OF BUSINESS:___________________________________________________________ FEDERAL I.D. __________________________________
ADDRESS:____________________________________________________________________________________________________________________________
IF A PARTNERSHIP IS LOCATED IN PARMA HEIGHTS, GIVE NAME AND ADDRESS OF EACH PARTNER:
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
10. DO YOU OR YOUR SPOUSE OWN RENTAL PROPERTY, INCLUDING FARM RENTAL?
_________________YES _____________________NO
IF YES, ADDRESS OF RENTAL PROPERTY _______________________________________________________________________________________________
11. DO YOU OWN YOUR PLACE OF RESIDENCE IN PARMA HEIGHTS? ________YES _________NO
IF YES, DATE OF PURCHASE _______________
IF NO, GIVE NAME AND ADDRESS OF OWNER:___________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
____________________________________________________________________________
SIGNATURE
DATE
FAILURE TO FILE THIS FORM WITHIN (15) DAYS MAY RESULT IN THE IMPOSITION OF PENALTIES PER THE INCOME TAX CODE. ALL INFORMATION
PROVIDED ON THIS FORM IS CONFIDENTIAL AND IS USED FOR CITY INCOME TAX PURPOSES ONLY. IF YOU HAVE ANY QUESTIONS REGARDING THIS
FORM, PLEASE CALL (440) 888-6440.
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