City of Mansfield 
                                                                                     Income Tax Division 
                                                                                               P.O. Box 577 
                                                                                     Mansfield, OH 44901 
                                                                   Phone: 419-755-9711   Fax: 419-755-9751 
                                                                                     www.ci.mansfield.oh.us 

                                                                   BUSINESS AND PROFESSIONAL QUESTIONNAIRE 

                      For the purpose of our records, with regard to Mansfield Income Tax, please complete and return this 
                      Questionnaire promptly.   

                      1. Local name and address as used for business purposes:
                                                 _____________________________________________________________________________________

                                                Trade Name: __________________________________________________________________________

                      2. Location in Mansfield or Work Site: ________________________________________________________

                      3. Type of work to be performed: ____________________________________________________________

                      4. Date started in Mansfield: ________________________________________________________________

                      5. Expected duration of work: _______________________________________________________________

                      6. Federal I.D. or Social Security #: ___________________________________________________________
                      7.                        Accounting period used for Federal Income Tax purposes:
                                                (Check applicable box-if fiscal write in date)  Calendar Year Ending December 31
                                                                                                Fiscal Year Ending  ________________________ 
                      8.                        Do you now employ one or more persons in Mansfield?         Yes     No
                                                Date Employees started in Mansfield: _________________________________________________ 
                      9.                        Do you expect to have employees in the future?  Yes         No
                                                When? ______________________________________________________________________________

MonthlyTax:10.            Projected                                                                                                                     Withholding ___________________________________________________
                      11. Does your company voluntarily withhold tax for Mansfield residents not employed inside the City of
                                                Mansfield? (If yes, only complete the front of the form)       Yes    No
                      12. Company Phone: _________________________                                       Fax: ____________________________________  

                                                Net Profit Return:                                       Employee Withholding Tax Form: 

                                                Name:  _________________________________                 Name:  _________________________________  

                                                Contact Person: __________________________               Contact Person: __________________________  

                                                Street Address:  __________________________              Street Address:  __________________________  

                                                City: _______________  State  ____ Zip _______           City: _______________ State _____ Zip _______  

                                                Email: __________________________________                Email: __________________________________  

13. Projected Yearly Revenue:   Less Than $500,000 Annual Revenue  
                                More Than $500,000 Annual Revenue 14. 

Type of Ownership (check which):

        Non-Profit Corporation                        Individual Proprietorship (Complete 15a)  
          Corporation (Complete 15b)                  Partnership (Complete 15C) 

15. Owner’s Name and Address
    a. If Individual Proprietorship, give owner’s name, social security number, and address:
         Name: _____________________________________________________
         Social Security Number: _______________________________________ 
         Street Address: ______________________________________________ 
         City: _____________________________  State ________ Zip __________ 
    b. If corporate subsidiary, give name and address of parent company main office:
         Name: _____________________________________________________
         Federal ID Number: __________________________________________ 
         Street Address: ______________________________________________ 
         City: _____________________________ State ________ Zip __________ 
         Will you be filing a consolidated return:    Yes           No 
    c. If partnership, association, or other incorporated joint business venture, list names and addresses of
         partners, association, or members
         Name   SS# or Fed ID#                        Street Address        City    State  Zip 
    __________________________________________________________________________________  

    __________________________________________________________________________________  

    __________________________________________________________________________________  

    __________________________________________________________________________________  
    Note: Throughout this questionnaire, wherever listings are required-attach a separate list if sufficient 
    spaces have not been provided. 
16. With reference to real estate properties located within the City of Mansfield:
    Does the business occupy, as a tenant, real estate property in
    Mansfield rented from others?    Yes          No
    If so, to whom is rent paid: (Give owner, if known, otherwise his agent)
    Name        SS# or Fed ID#                    Street Address       City        State        Zip
    _____________________________________________________________________________________
17. Do you operate any other business within the City of Mansfield?      Yes  No
    Note: Other business includes rental properties rented to others
    If you do, list those located within the City:
    _____________________________________________________________________________________
    _____________________________________________________________________________________

                So that further correspondence will not be necessary, 
                we ask your cooperation in filing this form promptly.  
                                                  THANK YOU