WARREN CITY INCOME TAX DEPARTMENT 
                       INDIVIDUAL QUESTIONNAIRE 
 
Please complete the following questions to the best of your ability.  This information 
enables our office to establish a tax account for you.  If you are currently filing a 
Warren City Income Tax Return, your account will be updated.  If you do not have a 
current tax account, one will be set up for you and additional information will 
follow.  Please submit within 10 days of receipt. 
 
Name ___________________________________    SSN # _____________________________ 
 
Spouse __________________________________   SSN # _____________________________ 
 
Address _________________________________    Date Moved In  ______________ 
 
       _________________________________ 
 
 Phone No. ___________________________________   Today’s  Date _____________________ 
 
     1.  Did you live in Warren any time during the past 5 years?  □ YES    □ NO 
          If YES, list all addresses and applicable dates:     Date From - Date To: 
      
     _____________________________________________________________ 
     _____________________________________________________________ 
     _____________________________________________________________ 
     _____________________________________________________________ 
     _____________________________________________________________ 
      
     2.  Did you file a Warren City Income Tax Return last year?  □ YES   □  NO    
      
     3.  Are you presently employed?        □  YES      □  NO 
        Spouse employed?                         □  YES      □  NO 
 
     4.  If unemployed, do you receive      □   SSI           □   ADC                                                        
             □   Permanent Disability   □   State Unemployment    
      
     5.  Are you retired?              □  YES     □  NO        Date Retired__________ 
          Spouse retired?               □  YES     □  NO        Date Retired__________ 
      
     6. List any other Warren resident living in your home over the age of 16 years old who 
        has earned income. 
      
        Name_____________________________   SSN ________________ 
        Name_____________________________   SSN ________________ 
              
                       PLEASE COMPLETE REVERSE SIDE 
      

   7.   List below each employer (starting with your present or last employer) during the  
         past five (5) years.   
       EMPLOYER                                      DATE FROM – DATE TO 
     ___________________________________________________________ 
               ___________________________________________________________ 
     ___________________________________________________________ 
     ___________________________________________________________ 
     ___________________________________________________________ 
                           
         If Spouse has been employed at any time during the past five (5) years, list below. 
     ___________________________________________________________ 
     ___________________________________________________________ 
     ___________________________________________________________ 
     ___________________________________________________________ 
     ___________________________________________________________ 
    
   8.   Have you been the proprietor of a business in Warren during the past  
         five (5) years?                                        □ YES     □  NO 
     If yes, list name and location of business. 
     ___________________________________________________________ 
     ___________________________________________________________ 
 
   9.   Do you own or are you buying the home you live in?    □ YES     □  NO 
    
   10. Do you own rental property in the city of Warren?        □  YES     □  NO 
     If yes, list locations of all rental property and the amount received monthly. 
    _________________________________________________________ 
    _________________________________________________________ 
    _________________________________________________________ 
    _________________________________________________________ 
     
 I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT 
 
Signature ____________________________________________________________  Date __________________ 
 
Spouse ______________________________________________________________  Date __________________ 
 
This Questionnaire must be submitted to the Income Tax Department whether or not 
there is any liability for Warren City Income Tax.  All persons who are subject to the 
tax imposed by Warren Ordinance must file an annual return whether or not a tax is 
due.  The tax rate is 2%. 
 
       For questions concerning this form call (330) 841-2551. 
 
                          Warren City Income Tax Department 
                                 418 Main St SW 
                                 PO Box 230 
                                 Warren, OH 44482 
                                 FAX: (330) 841-2626