City Of Blue Ash Confidential Resident Questionnaire Form printable pdf download

Income Tax Division

City of Blue Ash

4343 Cooper Road - Blue Ash, Ohio 45242-5699

Phone: (513) 745-8516; Fax: (513) 745-8651

Or Email Address:

CITY OF BLUE ASH CONFIDENTIAL RESIDENT QUESTIONNAIRE

ADDRESS ______________________________________________________

PHONE NO. ___________________

ACCT. NO. ________________

House No.

Street

Apt.

Zip Code

(Office Use Only)

YOUR NAME________________________________

SOCIAL SECURITY NO. ____________________________

MOVE-IN DATE ___________________

EMPLOYER ___________________________________

ADDRESS WHERE YOU WORK ___________________________________________________

Do you pay earnings tax to a city? _________

If so, what city? ______________________

Date present employment began __________________________

Do you or does anyone in your household receive a refund from your city of employment? ___________

If so, who? _____________________________________

Do you have business income? ___________

In Blue Ash? _______________

Where? ____________________________________________________

SPOUSE’S NAME ____________________________

SOCIAL SECURITY NO. ___________________________

MOVE-IN DATE ______________________

EMPLOYER ____________________________

ADDRESS OF EMPLOYMENT__________________________

DATE PRESENT EMPLOYMENT BEGAN___________

Does spouse pay earnings tax to a city?__________________

If so, what city? ______________________________

NOTE: LIST BELOW ALL OTHER HOUSEHOLD OCCUPANTS REGARDLESS OF EMPLOYMENT STATUS. USE ADDITIONAL PAPER IF NECESSARY.

Name

Soc. Sec. #

Employer

Date Began

Address of Employment

Pay Taxes to What City?

If anyone listed above pays City taxes through their employer, you must include a copy of a recent pay stub or W-2 with this form. This information will

exempt you from filing a yearly Blue Ash Tax Return if your taxes are fully withheld and no refund is received from city of employment.

If you rent, give name and address of landlord __________________________________________________________________________________________________

If any member of your household owns rental property, give name __________________________________________________________________________________

Address of rental property ___________________________________________________________ Date acquired for rental _______________________________

Name of current tenant (if property located in Blue Ash) ___________________________________

I hereby certify that to the best of my knowledge the above information is true, correct, and complete.

SIGNATURE _____________________________________

Date _______________________

Please return completed form to: Blue Ash Tax Office, 4343 Cooper Road, Blue Ash, OH 45242-5699 or fax to (513) 745-8651. If any of the above information changes, you

are required to notify us within thirty (30) days.

WRQ

7-2005

City Of Blue Ash Confidential Resident Questionnaire Form

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