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| CITY OF AMHERST, OHIO INCOME TAX DEPARTMENT 480 Park Avenue Amherst, OH 44001-2258 Phone ( 440) 988-4212 Fax ( 440) 988-3749 Email: incometax@amherstohio. org Richard S. Ramsey Treasurer 1. Name: ______________________________________________________________ | CITY OF AMHERST, OHIO INCOME TAX DEPARTMENT 480 Park Avenue Amherst, OH 44001-2258 Phone ( 440) 988-4212 Fax ( 440) 988-3749 Email: incometax@amherstohio. org Richard S. Ramsey Treasurer 1. Name: ______________________________________________________________ |
| SSN ____________________________ | SS# _______________________ |
| 2. Spouse’s Name: _____________________________________________________ | 2. Spouse’s Name: _____________________________________________________ |
| SSN ____________________________ | SS# _______________________ |
| 3. Address: ___________________________________________________________ Apt #. ________ 4. Phone: ( ) ________________________ Date Moved Into Current Location: | 3. Address: ___________________________________________________________ Apt #. ________ 4. Phone: ( ) ________________________ Date Moved Into Current Location: |
| _____/_____/_____ | ____________ |
| 5. Previous address if located in the city: ____________________________________________________ 6. Do you own your place of residence in the city of Amherst? _______ Yes _______ No If renting, please give the name and address of owner | 5. Previous address if located in the city: ____________________________________________________ 6. Do you own your place of residence in the city of Amherst? _______ Yes _______ No If renting, please give the name and address of owner |
| __________________________________________________ | |
| __________________________________________________ 7. | __________________________________________________ 7. |
| Do you or your spouse own rental property? _______ Yes _______ No 8. | |
| Email Address: ______________________________________ | Email Address: ______________________________________ |
| 9. | 8. |
| Give name, | Give name, |
| SSN | birth |
| | date |
| and | and |
| DOB | SS# |
| of all others residing at this address: | of all others residing at this address: |
| NAME SSN | Name SS# |
| DOB | DOB |
| 10. | ________________________________ |
| | __________________ ___________ ________________________________ _________________ ___________ ________________________________ _________________ ___________ ________________________________ _________________ ___________ ________________________________ _________________ ___________ 9. |
| If you or your spouse | If you or your spouse |
| are | is |
| not employed, please | not employed, please |
| complete | place |
| | a date in front of |
| the | the |
| grid below by checking | statement that most accurately |
| | describes your status: Yourself Spouse Retired Since _____________ ____________ Disabled Since _____________ ____________ 10. How would you like to file your city tax return? _______ Jointly _______ Separately ( This does not have to match |
| the | the |
| appropriate box. Name Retired – | federal filing status) 11. Do |
| | you or your spouse have income from self-employment? _______ Yes _______ |
| No | No |
| Disabled – | If yes, |
| | give the name and address of the business ______________________________________ Fed. ID# ____________ ______________________________________ 12. Do you or your spouse own rental property? _______ Yes _______ |
| No | No |
| Earned Income Earned Income | |
| By signing this form, I acknowledge that all statements are true to the best of my knowledge. I also acknowledge that I have received a copy of “Tax Information for Amherst City Residents. ” ________________________________________________________ Signature Date All information provided on this form is confidential and is used for city income tax purposes only. Rev | By signing this form, I acknowledge that all statements are true to the best of my knowledge. I also acknowledge that I have received a copy of “Tax Information for Amherst City Residents. ” ________________________________________________________ Signature Date All information provided on this form is confidential and is used for city income tax purposes only. Rev |
| 10-22 | 10-19 |
| PDF file checksum: | PDF file checksum: |
| 530134992 | 1418616130 |