Personal Income Tax Questionnaire Form
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1Personal Income Tax Questionnaire
For City of Dayton, Ohio
Name
Social Security #
required
Spouse
Social Security #
required
Questionnaires with spouse information will be set up as JOINT FILING, unless you request separate accounts.
Present Address
City
State
Zip
Date you moved to current address
required to establish beginning date of tax liability.
Prior Address
City
State
Zip
Dates
SOURCE OF INCOME;
Name of your Employer
Is Employer withholding city tax?
Yes
No for what city?
@ rate%?
Name of your Spouse’s Employer
Is Employer withholding city tax?
Yes
No for what city?
@ rate%?
If Self-Employed:
Business Name
Type of Business
Business Address
Do you have employees?
Yes
No
If YES, your Federal ID#
Do you own rental property and receive income (or report losses) from the rent:
If yes, give locations of property:
Other income, e.g. partnerships, estates, trusts, etc.
Names and Social Security #s of other members of the household over 16 years:
If you are not liable for city tax, please give reason:
Active Duty Military income, Social Security, unemployment benefits, pensions, dividends, and interest are not taxable.
You may still be required to FILE a return.
Signature
Date
Phone # Home
Signature
Date
Phone # Work
E-mail address
@
Phone # FAX
It is required by local income tax ordinance that this questionnaire be fully completed and returned by
mail to the City of Dayton, P. O. Box 1830, Dayton, Ohio, 45401 or by fax (both sides of letter) to
(937) 333-4280. This will allow us to correctly set up (or make corrections to) your account and mail you the
proper tax forms. Thank you for your cooperation.
If you have any questions, please call us at (937) 333-3500between 8.00 am through 5.00 PM
Monday through Friday.
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