Form Itb-3 - Business Questionnaire Form
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1CITY OF SPRINGFIELD, OHIO
INCOME TAX DIVISION
for office use only:
Approved By__________
76 E. High St.
Springfield, OH 45502
Date ________________
Phone (937) 324-7357
Fax: (937) 328-3471
EMail: mhart@ci.springfield.oh.us
BUSINESS QUESTIONNAIRE
Name & address of all owners, partners, or principal corporate officers
NAME
ADDRESS
SSN
TELEPHONE
_____________________________________________________________________________________
_____________________________________________________________________________________
TYPE OF BUSINESS
Sole Proprietor
Partnership
Corporation
Other (specify) _____________
Charter Number __________________________
Business Name ________________________________________________________________________
Nature of Business _____________________________________________________________________
HOME OFFICE Address _________________________________________________________________
Phone ___________________________
Fax _________________________________
E-Mail
__________________________________________________
Contact person
_________________________________________
SPRINGFIELD LOCATION
Date business started in Springfield
_____________________________________
Date employees began ______________________
Approximate Number ______________
Local business address _______________________________________________________
ACCOUNTING INFORMATION
Federal Identification Number_______________________
Social Security Number (if sole proprietorship) _____________________________________
Calendar Year ____________ or
Fiscal Year Ending ______________________________
Name/address of bookkeeper/accountant _________________________________________
Please indicate payroll company, if applicable: _____________________________________
Will other payments be made for services rendered? Yes _____________ No ___________
If yes please note type:
Commissions,
Bonuses,
Subcontractors,
Director’s Fees, or
Other (specify): _________________________________________________________________________
TO BE COMPLETED BY CONTRACTORS AND/OR SUBCONTRACTORS
Name and address of party from whom contracted ____________________________________________
_____________________________________________________________________________________
Location of job _______________________________________________________________________
Probable length of job: From _____________________ To____________________________________
Are you or will you be subcontracting any work to someone else? Yes ___________ No ______________
If “yes”, attach list of names, addresses, type of work, amount paid *
Are you now or will you be doing more than one job in Springfield? Yes ___________ No _____________
Are you licensed by the City of Springfield Building Inspector?
Yes ___________ No ______________
If yes, please give name and address of individual licensed _____________________________________
_____________________________________________________________________________________
_______________________________
________________________________ ______________________________
RESPONDENT’S NAME
TITLE
DATE
Your Springfield account number will be assigned and e-mailed or faxed to you within 2 business days.
ACCOUNT NUMBER ____________________________________
Form ITB - 3 (Rev 1/07)
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Parent category: Financial