Resident Information Sheet - City Of Canton

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Resident Information Sheet
Name _______________________________Social Security Number_____________________
Name (Spouse) _______________________Social Security Number _____________________
Address ________________________________Telephone Number ______________________
City/State/Zip _____________________________Date of Birth _________________________
Date Moved Into Canton _______________________ Spouse Date of Birth ________________
Employees Company Name(s) and Location
Dates of Employment
19 ________________________________________________________________________________________
19 _________________________________________________________________________________________
19 _________________________________________________________________________________________
19 _________________________________________________________________________________________
19 _________________________________________________________________________________________
19 _________________________________________________________________________________________
Is city tax withheld by employer(s)? _______Yes ________No
To what city or cities do you pay the tax? _________________________________________________________
Are you self-employed? _______Yes _______No (If yes, please fill out business activity section on back of form)
Do you own rental property? _______Yes _______No (If yes, please fill out rental section on back of form)
Do you have Royalty income? _______ Source of Royalty ____________________________________________
If not employed, what is your source of income? Please circle all that apply: Social Security Pension
Interest
Dividends
Disability
Workers Compensation
Alimony
ADC
Other (Please Specify)
Are you presently filing with our office or have you previously filed with our office? ______Yes ______No

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