Individual Questionnaire Form printable pdf download

Individual Questionnaire Form

CITY OF FAIRBORN INDIVIDUAL QUESTIONNAIRE

Income Tax Division

44 W. Hebble Ave.

Fairborn, Ohio 45324-4999

The following information will assist us in determining your tax liability.

Please answer all questions and mail this

questionnaire to the above address or you may fax the completed questionnaire to (937) 754-3054. If you have any questions

concerning this questionnaire or our municipal income tax, please contact us at (937) 754-3006. Please return within 15 days.

Name:

Social Security Number

Spouse:

Social Security Number

Address

Date you moved into Fairborn:

Date your spouse moved into Fairborn:

PLEASE LIST YOUR

SOURCE(S) OF INCOME:

You

Spouse

Employer:

Employer Address:

Active Duty Military:

(List State of Legal Residency)

Only Non-Taxable:

(List Source)

If Self-Employed:

Business Name:

Business Address:

Do you or your spouse own property and receive income (or report losses) from rent?

If yes, list the address of each property:

List any other sources of income (e.g. partnerships, estates, trusts, etc.)

List other members of your household over age eighteen (18):

(1)

(2)

Name:

Social Security Number:

Fairborn has mandatory filing for all persons residing in Fairborn and are 18 years of age or older.

Individual Questionnaire Form