Form It 1 - Application For Registration As An Ohio Withholding Agent - 2014

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IT 1
Rev. 8/14
Application for Registration
07100100
P .O. Box 182215
as an Ohio Withholding Agent
Columbus, OH 43218-2215
(888) 405-4089
Employer withholding account no.
(For department use only)
Federal employer identifi cation no.
Ohio corporate charter no. / certifi cate no.
Reactivate for account number? Yes. If yes, provide number if available.
Yes
Will you have an employee that resides in a taxing school district?
No
1. Check type of ownership:
Sole owner
Partnership
Corporation
Nonprofi t
LLC
LLP
LTD
Single member LLC
Other (please specify)
2. Date of fi rst Ohio payroll, if known (MM/DD/YY)
(For the most current listings, search
3. Provide NAICS code and state nature of business activity
NAICS on our Web site at tax.ohio.gov.)
4. Legal name
(Corporation, sole owner, partnership, etc.)
5. Trade name or DBA
6. Primary address
Address of corporation, sole owner, partnership, etc.
City
State
ZIP code
Business phone no.
Fax no.
Secondary phone no.
7. Mailing address
(If different from above)
City
State
ZIP code
8. Check the box applicable to your estimated employer withholding remittance amount per year:
Less than $2,000 a year
At least $2,000, but less than $84,000
Greater than $84,000
9. Ohio liquor permit number (if any)
10. Information for individual responsible for fi ling returns and making payment of Ohio and school district withholding taxes:
Name
Title
Phone no.
SSN / ITIN
City
State
ZIP code
11. Name, phone number, fax number and e-mail address of individual the department should contact regarding this account
Name
Phone no.
Fax no.
E-mail address
Date
Signature of applicant
Federal Privacy Act Notice
Because we require you to provide us with a Social Security number, the Federal Privacy
Act of 1974 requires us to inform you that providing us with your Social Security number is
mandatory. Ohio Revised Code sections 5703.05, 5703.057 and 5747.08 authorize us to
request this information. We need your Social Security number in order to administer this tax.

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