Individual Questionnaire - City Of Fairfield

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City of Fairfield
INDIVIDUAL QUESTIONNAIRE
Date: _____________
The following information is needed to complete our records. Failure to complete will require a
personal appearance to our office for this information. Please assist us in this matter. (If
retired or disabled, please indicate in the space allocated for employer.)
Taxpayer Name:
___________________________________________
Address:
_________________________________________________________________
_________________________________________________________________
Social Security Number:
_____-_____-______ Home Phone Number
(____) ____-_____
Name of Employer:
_______________________________________________________
Address of Employer:
____________________________________________________
Is local tax withheld by the employer?
_______ If yes, for which city?
______________
Spouse’s Name:
____________________________________________________________
Social Security Number:
_____-_____-______ Home Phone Number
(____) ____-_____
Name of Spouse’s Employer:
_______________________________________________
Address of Spouse’s Employer:
___________________________________________
Is local tax withheld by the employer?
_______ If yes, for which city?
_____________
Date moved into Fairfield:
_______________
Do you (check one):
_____ Rent
_____Lease
_____ Own
If you have any questions, please contact us at the number listed below. Thank you for your
cooperation on this matter.
Sincerely,
Mary Hopton
Income Tax Administrator
cc: File
INCOME TAX DIVISION
5350 Pleasant Avenue, Fairfield, Ohio 45014 513-867-5327 (TDD-867-5392)

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