Form Wiq - Official Income Tax Information Questionnaire

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City of Greenville Income Tax
Municipal Building, 100 Public Square
Greenville OH 45331
Phone 937-548-5747 Fax 937-548-3035
(FORM WIQ)
Official Income Tax Information Questionnaire
PLEASE COMPLETE ALL QUESTIONS AND RETURN THIS FORM. DO NOT DISREGARD.
The information requested on this form is essential for the completion of our records and will be kept confidential.
Authorized by Ordinance No. 04-129
PLEASE PRINT OR TYPE
1. Name
Social Security No.
Date of birth
Address
City
State
Zip
Spouse's Name
Spouse's Soc. Sec. No.
Date of birth
Spouse's Address
City
State
Zip
Date moved into Greenville city limits
Telephone No.
Cell Phone No.
If you no longer live in Greenville, list the dates you lived within Greenville city limits
Do you own or rent your place of residence? Own
Rent
If renting, give name and address of landlord
2. Your source of income:
W-2 Income;
Self Employment;
Active Military;
Retirement;
Unemployment benefits;
Farm
Income;
ADC;
Welfare;
Alimony;
Child Support;
Supported by relative or friend;
Other:
3. Spouse source of income:
W-2 Income;
Self Employment;
Active Military;
Retirement;
Unemployment benefits;
Farm
Income;
ADC;
Welfare;
Alimony;
Child Support;
Supported by relative or friend;
Other:
4. Do you receive rental income? Yes
No
If yes, give address of each rental property, date acquired and list of all tenants. (Attach list if necessary)
ADDRESS
DATE ACQUIRED
NAME(S) OF TENANTS
5.
List names of any other persons, 18 years of age or over, including college students living at this address either part-time or full-
time during calendar year:
Name
Social Security No.
Date of birth
Source of income:
W-2 Income;
Self Employment;
Active Military;
Retirement;
Unemployment benefits;
Farm
Income;
ADC;
Welfare;
Alimony;
Child Support;
Supported by relative or friend;
Other:
Name
Social Security No.
Date of birth
Source of income:
W-2 Income;
Self Employment;
Active Military;
Retirement;
Unemployment benefits;
Farm
Income;
ADC;
Welfare;
Alimony;
Child Support;
Supported by relative or friend;
Other:
Name
Social Security No.
Date of birth
Source of income:
W-2 Income;
Self Employment;
Active Military;
Retirement;
Unemployment benefits;
Farm
Income;
ADC;
Welfare;
Alimony;
Child Support;
Supported by relative or friend;
Other:
The statements made on this questionnaire are true, correct and complete to the best of my knowledge.
(Signature)
(Date)
(Spouse - Signature)
(Date)
IF YOU HAVE ANY QUESTIONS OR NEED ASSISTANCE IN COMPLETING THIS FORM, PLEASE CONTACT THE
GREENVILLE TAX OFFICE AT (937) 548-5747. PLEASE RETURN WITHIN TWENTY (20) DAYS.

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