WITHHOLDING AND BUSINESS REGISTRATION 

                               CCA – MUNICIPAL INCOME TAX
                                                    205 W Saint Clair Ave
                                              Cleveland OH 44113-1503 
                                              Phone: 216-664-2070, 1-800-223-6317    Fax: 216-420-8316
                                              www.ccatax.ci.cleveland.oh.us

DATE BUSINESS STARTED IN CCA                                      PHONE NO. 

FEDERAL IDENTIFICATION NUMBER 

NAME OR CORPORATE NAME 

BUSINESS OR TRADE NAME 

BUSINESS ADDRESS     IN TAXING COMMUNITY 

MAILING ADDRESS 
                  ADDRESS OF OUTSIDE ACCOUNTANT SHOULD NOT BE USED
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                               CHECK BUSINESS TYPE

SOLE PROPRIETOR**                                           CORPORATION
PARTNERSHIP                                                 LIMITED LIABILITY CO
S-CORPORATION                                               NON-PROFIT CORP
ESTATE OR TRUST                                             GOVERNMENTAL
FINANCIAL ORG.                                              UNION
OTHER                                         (Detail)
          **IF**IFSOLESOLEPROPRIETORPROPRIETORYOUYOUMUSTMUSTALSOCOMPLETECOMPLETEBOTH INDIVIDUALSIDES OF THISREGISTRATIONFORMFORM
                  It is your responsibility to advise this office of any changes in your status
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Will you be withholding employment taxes?                       Yes                    No

For what CCA city(s) 

$200 or more per month?                                         Yes                    No

Number of employees in CCA?                              First payroll date in CCA

Will you be withholding residence taxes?                        Yes                    No

Type of business (Mfg., Commercial, etc.) 

Fiscal Period ending month 

Name of person responsible for filing forms: 

Name                                           Title                                  Phone No.

Signature                                                                             Date