Form It 1 - Combined Application For Registration As An Ohio Withholding Tax/school District Withholding Tax Agent

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IT 1
Department of
Rev. 12/09
Taxation
Combined Application for
07100100
P .O. Box 182215
Registration as an Ohio
Columbus, OH 43218-2215
(888) 405-4089
Withholding Tax/School District
Withholding Tax Agent
Employer withholding account no.
(For department use only)
Federal employer identifi cation no.
Ohio corporate charter no. / certifi cate no.
Social Security no. / ITIN
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: (10) Sole owner
(20) Partnership
(30) Corporation
(150) Nonprofi t
(50) LLC
(70) LLP
(80) LTD
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. Name, title and phone number of individual responsible for fi ling returns and payment of Ohio withholding/school district
withholding tax
Name
Title
Phone no.
9. 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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