Cca - Municipal Income Tax Form - Ohio
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1INDIVIDUAL REGISTRATION
CCA - MUNICIPAL INCOME TAX
1701 Lakeside Avenue
Cleveland, OH 44114-118
Phone: 216-664-2070, 1-800-223-6317
Move in Date:
Phone No.
Primary Social Security No.
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-
Spouse Social Security No.
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Primary Name
Spouse Name
Street Address
Apt. No.
City
State
Zip Code
Prior Address:
City
State
Lived at prior address: From
To
LIST ALL OTHER RESIDENTS IN HOUSEHOLD (AGE 18 OR OVER)
NAME
AGE
SOCIAL SECURITY NO.
CITY WHERE EMPLOYED
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-
-
-
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-
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EMPLOYMENT (GIVE NAME AND ADDRESS OF EMPLOYER(S) - INDICATE WHETHER FOR
YOURSELF OR SPOUSE FOR THE LAST TWO (2) YEARS. SHOW LAST JOB FIRST.
COMPANY NAME
ADDRESS/CITY
CHECK ONE
1.
SELF
SPOUSE
2.
SELF
SPOUSE
3.
SELF
SPOUSE
4.
SELF
SPOUSE
CHECK OTHER SOURCES OF INCOME:
RENT G
SOC. SEC. G
PENSION G
SELF-EMPLOYED G
OTHER G
TRADE NAME AND ADDRESS IF SELF-EMPLOYED
If registration is for employers or business,
you must complete the reverse side of this form.
SIGNATURE
DATE
The above signed declares that this statement is true and correct
CCA Form 120-1 (Rev. 11/00)
M E MB E R S
Paines ville
Seville
Creston
Geneva on the Lake
Madison
Mid dlefield
Ada
Paulding
Sout h Ru sse ll
Grand Rapids
Marblehead
North field
Andover
Dunk irk
Timberlake
Medina
North Baltimo re
Penins ula
Bratenahl
Euc lid
Grand River
North Perry
Perry
W adsworth
Burton
Fairport Harbor
Highla nd Hills
Men tor
Rock Creek
W arrensville Hts.
Gat es M ills
Liberty Center
Mentor on the Lake
North Ran dall
Chardon
Rocky River
W illoughby
Linnd ale
Meta mora
Orwe ll
Cleveland
Gen eva
W lilough by Hills
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Parent category: Financial