City of Reading, Ohio            Melvin T. Gertz 
                                                                                                TREASURER
                                           INCOME TAX BUREAU                                                                                  
                                              1000 MARKET STREET                                                             (513) 733-0300 
                                             READING, OHIO 45215-3283                         FAX (513) 842-1016      
Account number is the Federal ID# 

                EMPLOYER’S WITHHOLDING ACCOUNT QUESTIONNAIRE 
                           (Please Complete & Return Within Ten (10) Days) 

1.  Name of Business: ______________________________________________________________ 

2.  Social Security # or Fed ID # ______________________________________________________ 

3.  Business Address: ______________________________________________________________ 
                       Street Address                                       City / State / Zip 
  Telephone #: _____________________ Fax # ______________ E-MAIL___________________ 

4.  Please Check Appropriate Description: 
        A.  Please give location address in Reading: _____________________________________ 
        B.   Number of days on job site in Reading:    _____________________________________ 
        C.   Nature of business: ______________________________________________________ 
        D.   Number of employees at Reading address: ___________________________________ 
        E.   Withholding Start Date: ___/___/___ REMIT:  QTLY : _______    MONTHLY: ______ 
            F.    Payroll Service Name:____________________ 
        G.   Courtesy Withholding?  Yes___  No ___       Amount  ___ 2.0% ___ 1% ___ Other 

TYPE OF ORGANIZATION:      Individual Proprietor    Partnership     Corporation                Non-Profit 
                                Association    Limited Liability Corp. 
If a Partnership, Association, or other Unincorporated Joint Business Venture, indicate how the 
Reading Income Tax Return, based upon the net profit, will be filed and paid: 

  In Full By the Business                Separately by Individual Members 
If a Partnership, give Name, Title,  and Address of all Partners: 
________________________________________________________________________________
________________________________________________________________________________
____                                                                                                                   
5.     Contact Person: _________________________  Title: _________________________ 

6.     Business Accounting Period     Calendar Year       Fiscal     Year Ending ____________ 

7.     Opening Date of Business (in Reading) ____________________________________________ 

8.     Do you have Net Profits attributable to Reading?                 Yes      No   

9    Do you operate more than one Business in Reading?                   Yes       No 
        If Yes, give Name: _________________________ Fed ID# _________________________ 
        Address: _________________________________________________________________ 

______________________________     _______________________     ____________ 
Signature                                  Title                                      Date