Subcontracted Business And/or Individual Questionnaire Form - Blue Ash Income Tax Division

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SUBCONTRACTED BUSINESS AND/OR INDIVIDUAL QUESTIONNAIRE
BLUE ASH INCOME TAX DIVISION
4343 COOPER ROAD
BLUE ASH, OHIO 45242-5699
(513) 745-8516
NAME:
___________________________________________________________________________________
STREET:
________________________
CITY: __________________
STATE: _____ ZIP: _____________
SOCIAL SECURITY NO:
_____________________ FEDERAL ID NO: ___________________________________
DAYTIME PHONE NO:
_____________________ CONTACT PERSON: ________________________________
NATURE OF BUSINESS:
_________________________________________________________________________
o
o
ACCOUNTING PERIOD:
CALENDAR YEAR
OR
FISCAL YEAR ENDING ______________________
NAME OF COMPANY: ______________________________________________________________________________
CORPORATE OFFICERS (IF APPLICABLE):
TYPE OF BUSINESS:
o
SOLE PROPRIETORSHIP
PRESIDENT: ________________________________
o
PARTNERSHIP
TREASURER: _______________________________
o
S CORPORATION
o
CORPORATION
PARTNERS (IF APPLICABLE): NAME & ADDRESS:
o
1. ___________________ ____________________
LIMITED LIABILITY COMPANY
2. ___________________ ____________________
o
INDIVIDUAL
o
STATUTORY EMPLOYEE
STARTING DATE OF BLUE ASH ACTIVITY:
___________________________________________
NAME AND ADDRESS OF BLUE ASH JOBSITE: ___________________________________________
___________________________________________
Attach complete listing with addresses & phone numbers of
all subcontractors used.
NUMBER OF EMPLOYEES WORKING IN BLUE ASH: ___________________________________
HOW MANY HOURS WORKING IN BLUE ASH: ____ PER WEEK
____PER MONTH
____ PER YEAR
I CERTIFY THE ABOVE INFORMATION TO BE TRUE, COMPLETE, AND ACCURATE.
SIGNATURE: ______________________________
TITLE: _____________
DATE: _____________

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