Form Iq/07 - City Of Canfield Individual Questionnaire

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CITY OF CANFIELD INDIVIDUAL QUESTIONNAIRE
1 0 4 L I S B O N S T R E E T, C A N F I E L D, O H I O 4 4 4 0 6 - 3 3 0-5 3 3-1 1 0 1
INCOME TAX DEPARTMENT
DATE _________________
The City of Canfield has a 1% City Income Tax. To establish and maintain accurate records the Income Tax Ordinance
requires that you complete this questionnaire. This information is confidential and will only be used by the Income Tax
Department. Please answer all the questions and return this form to us. Thank you.
SELF:
SPOUSE:
1. Soc. Sec. # __________________________________
Soc. Sec. # __________________________________
2. If under age 18 - D.O.B. __________________
If under age 18 - D.O.B. __________________
3. Employer(s) ____________________________________
Employer(s) ___________________________________
4. Date moved to City _______________________
Date moved to City ________________________
5. Date moved from City _____________________
Date moved from City ______________________
6. Work phone # ____________________
Work phone # ____________________
7. Home phone # _____________________
8. If either of you is not employed, explain (i.e. student, retired, or disabled) and give date of retirement or disability, etc.
______________________________________________________________________________________________
9. If you or spouse have any other source(s) of income (commissions, rental, farm, business, partnership, etc.) list them:
______________________________________________________________________________________________
10. Have you ever filed a Canfield Tax Return? _______________
11. Prior Account # ___________________
12. List other individuals 18 and over that reside at above address.
NAME ______________________________________________
SOC. SEC. # _____________________________
NAME ______________________________________________
SOC. SEC. # _____________________________
13. If renting, give name and complete address of landlord: ___________________________________________________
_______________________________________________________________________________________________
14. _____________________________________________
15. _____________________________________________
Your Signature
Date
Spouse’s Signature
Date
Thank you,
Gail L. Friedenberger
Income Tax Clerk
IQ/07

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