Individual Income Tax Questionnaire Form - Ohio Income Tax Division
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1RESET FORM
INDIVIDUAL INCOME TAX
CITY OF KETTERING - INCOME TAX DIVISION
QUESTIONNAIRE
P.O. Box 293100 • Kettering, OH 45429
Phone: 937.296.2502 • Fax: 937.296.3242
Date:
Kettering Account Number:
Please complete this income tax questionnaire and return it to our office by the due date stated above. You may mail or fax your
completed questionnaire to our office. Please contact us if you have any questions. Forms and additional information may be obtained by
visiting our website. Note: The City of Kettering has a mandatory filing requirement which means that all residents of the City of
Kettering 18 years of age and older must file an income tax return with the city on an annual basis.
Taxpayer:
SSN#
DOB:
Spouse:
SSN#
DOB:
Current Address:
City, ST, Zip
Home Telephone #:
Work Telephone #:
Email Address:
Cell Phone #:
Date Moved to Current Address:
Former Address:
Do you:
Own or
Rent your home in Kettering?
Taxpayer Employer:
Employer Address:
Date began employment:
Date terminated employment:
Does your employer withhold city tax?
If Yes, for what city?
Spouse Employer:
Employer Address:
Date began employment:
Date terminated employment:
Does your employer withhold city tax?
If yes, for what city?
Are you Self-Employed? If yes, please complete the following:
Business Name / Type of Business:
Business Address / Date Business started:
Do you have employees?
If yes, please enter Federal ID Number:
Do you own Rental Property?
If yes, please provide a full listing of all rental properties. You may attach a separate
sheet to this questionnaire or use the rental questionnaire available on our website.
Do you have income from other sources, such as partnerships, estates, trusts, Form(s) 1099-Misc., or gambling winnings, etc.?
If yes, please explain:
Other members in your household 18 years of age and older:
Name:
SSN#
DOB:
Name:
SSN#
DOB:
Are you eligible to file for an exemption from the City of Kettering's mandatory filing requirement? If yes, please explain:
Taxpayer Signature:
Date:
Spouse Signature:
Date:
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