INDIVIDUAL REGISTRATION
                             CCA – MUNICIPAL INCOME TA X
                                         205 W Saint Clair Ave
                                     Cleveland OH 44113-1503 
                              Phone: 216-664-2070, 1-800-223-6317 
                                 www.ccatax.ci.cleveland.oh.us 

Move in Date:                                    Phone No
Primary Social Security No.   -        -         Spouse Social Security No. 
Primary Name                                     Spouse Name 
Street Address                                                                    Apt. No
City                                     State                                    Zip Code
Prior Address                            City                                          State                  Zip Code
Lived at prior address: From                   To
Mailing Address                          City                                          State                  Zip Code

                  LIST ALL OTHER RESIDENTS IN HOUSEHOLD (AGE 18 OR OVER)

  NAME                       AGE         SOCIAL SECURITY NO                       CITY WHERE EMPLOYED

                                                 -        -

                                                 -        -

                                                 -        -

                                                 -        -

                        EMPLOYMENT  (GIVE NAME AND ADDRESS OF EMPLOYER(S)
     INDICATE WHETHER FOR YOURSELF OR SPOUSE FOR THE LAST TWO (2) YEARS. SHOW LAST JOB FIRST
     COMPANY NAME                        ADDRESS/CITY 

1.                                                                                SELF    SPOUSE

2.                                                                                SELF    SPOUSE

3.                                                                                SELF    SPOUSE

4.                                                                                SELF    SPOUSE

CHECK OTHER SOURCES OF INCOME:
RENT           SOC.SEC.      PENSION     SELF-EMPLOYED                            OTHER
TRADE NAME AND ADDRESS IF SELF-EMPLOYED

                             If registration is for employers or business,
                  you must also complete the Business Registration form.

SIGNATURE                                                                         DATE
                The above signed declares that this statement is true and correct.
                                                                                          CCA Form 1-20-1 (Rev. 6/08)