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KIM R. PEREZ                                                                                                                                                                  City of Canton
TREASURER, CITY OF CANTON
cantonincometax.com
                                                                                             INCOME TAX DEPARTMENT
Hours: 8:00-4:00
Monday thru Friday                                                                                              MAILING ADDRESS:                  PO BOX 9940, CANTON, OHIO 44711
                                                                                                                             OFFICE ADDRESS:  424 MARKET N., CANTON, OHIO 44702
                                                                                                                                                                              PHONE (330) 430-7900

                                                      Business & Corporation 

                                                      BusinessInformation& CorporationSheet
                                                                              Division of Compliance

         City of Canton             JEDD - FP             JEDD - TWR/SS            InformationJEDD - CD             JEDD - SMSheet
                                                                              Division of Compliance
                                                   JEDD - TSG            JEDD - TGAB           JEDD - Faircrest

Owner’sOwner’s Name____________________________________Name____________________________________ TelephoneTelephone NumberNumber _________________________

Owner’sOwner’sAddress__________________________________Address__________________________________SocialSocialSecuritySecurityNumber______________________Number  

                            City___________________________ State____________ Zip___________City___________________________ State____________ Zip___________

BusinessBusinessName______________________________________Name______________________________________FID.FID.NumberNumber(if(ifcorporation)_______________corporation) 

BusinessBusinessAddress____________________________________Address____________________________________BusinessBusinessPhonePhone __________________________

                            City___________________________ State____________ Zip___________City___________________________ State____________ Zip___________

NatureNatureofofBusinessBusiness____________________________________________________________________________________________________________________________________________________

If Subsidiary, List Name of Parent Co  If Subsidiary, List Name of Parent Co___________________________________________________________

Type of Ownership (Please Circle)Type of Ownership (Please Check)

         Sole Proprietorship        Sole Proprietorship    Partnership        Partnership    Not-For-ProfitNot-For-ProfitCorp       Corp   Corporation        Corporation     AssociationAssociation

WillWillYourYourBusinessBusinessHaveHaveEmployees?    Employees?    Yes     Yes      No        No        ContractContractWorkers?    Workers?      Yes    Yes      No         No

DateDateStartedStartedororMovedMovedtotoCantonTaxing Districtor DateorBusinessDate BusinessActivityActivityBegan inBeganCanton             in___________________________Taxing District 

IfIfpartnership,partnership,associationassociationororotherotherunincorporatedunincorporatedjointjointbusinessbusinessventure,venture,pleasepleaselistlistnamesnamesandandaddressaddressofofall all
partners,partners,associatesassociatesorormembersmembersininventureventureononbackbackofofform. form. IfIfpartnership,partnership,willwillpartnerspartnersfilefileseparately?  separately?  Yes   Yes   NoNo
AccountingAccountingPeriodPeriodUsedUsedforforFederalFederalIncomeIncomeTaxTaxPurpose:Purpose:
                                                        CalendarCalendarYearYearEndingEndingDecDec31      31      FiscalFiscalYearYearEndingEnding________________________________________ 

Accountant’s Name                         Address                                City                      State                      ZipAccountant’s Name                         Address                                City                      State                      Zip

 __________________________________________________________________________________________

IfIfyouyouoperateoperateanyanyotherotherbusinessbusinesswithinwithinororoutsideoutsidethethecitycityofofTaxingCanton,District,please listpleasebelow.list below.

DoDoyouyoupaypayrentrentononanyanyofficesofficesororbuildingsbuildingsininCanton?         Canton?        Yes    Yes      NoNo

                                                                                                                Name                                Address               CityName                                Address               City

If yes, please list name(s) & address(es) of landlord(s)  
If yes, please list name(s) & address(es) of landlord(s) _____________________________________________

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Address where tax forms and other correspondence are to be mailed

Name _________________________________________________________

Care of ________________________________________________________

Address _______________________________________________________

City______________________________ State___________ Zip__________

                           Partners, Associates or Members in Joint Venture

Name                                        Address                          City State Soc Sec #

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

                                                    Other Business

Business NameBusiness Name                  Address Address Nature of Business    Nature of BusinessTaxing District

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Under penalties of perjury, I declare that I have examined this questionnaire and accompanying documents, and, to the best of my knowledge
and belief, the information provided herewith is true, correct, and complete.

Signature_______________________________________________ Title____________________________ Date____________________________