Courtesy Withholding Questionnaire Form - City Of Canfield Income Tax Department
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1COURTESY WITHHOLDING QUESTIONNAIRE
CITY OF CANFIELD INCOME TAX DEPARTMENT, 104 LISBON STREET, CANFIELD, OHIO 44406-1416
Phone: 330-533-1101 ~ Fax: 330-533-2668 ~ Web-site:
~ E-mail:
vshook@ci.canfield.oh.us
Name:
Address:
DATE:
This form is only for non resident employers who withhold the City of Canfield income tax as a courtesy to
their employees who live in the City of Canfield. Contact the Income Tax Department at the above number to make
sure the employee’s address is in the City limits or go to our website, listed above, and check the “List of Streets in the
City of Canfield”. You can also go to , click on Auditor and then click on property search
or go to the Ohio Department of Tax at , go to The Finder and look up an address to check on the
taxing district.
To establish and maintain accurate records, the Income Tax Ordinance requires that you complete and return this form.
PLEASE PRINT.
1. Federal I.D. No. _________________________________
2. Soc. Sec. No. ________________________
3. Local name & address used for business purposes: Trade Name ________________________________________________
Location _____________________________________________________________________________________________
4. Nature of business conducted ____________________________
5. Contact’s Name _______________________________
6. Phone # & extension ______________________
7. E-mail address _____________________________________________
8. Date withholding began _______________ 9. Attach name, address, & SSN of employee for verification of tax to be
withheld.
10. Will you have $100.00 or more per month in withholding? ______
11. If a payroll service is used please give name of
service, contact person, and phone number _________________________________________________________________
12. Type of ownership: ___ Individual Proprietorship ___ Corporation ___ S Corp ___ Partnership ___ LLC ___ Non-Profit
13. If payroll service is not used send WH Forms To:
Company Name _____________________________________ Care of ______________________________________________
Street Address __________________________________________________________________ PO Box_________________
City _________________________________ State _______ ZIP __________________
14. I do hereby certify to the best of my knowledge, the above information is true, correct and complete
_______________________________________________
____________________________________________________
Name (Individual)
Signature
Date
_______________________________________________
____________________________________________________
Company
Title
_______________________________________________
____________________________________________________
Street Address
Phone #
Extension #
___________________________________________________
City
State
Zip Code
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