City of Brunswick, Ohio 
                                  Individual Registration 

Please complete the following questionnaire. This information is needed to establish accurate 
and updated records for the Income Tax Department. 
 
Date moved in: _____________         Address:_________________________________________  
Own ___    Rent ___  Landlord’s name & address (if renting):_____________________________ 
 
Name: __________________________________   Social Security Number: ________________ 
Date of Birth: ______________ 
Place of employment: _________________________     Date hired: ____________________ 
 
Spouse’s name: ___________________________  Social Security Number: ________________ 
Date of Birth: ______________ 
Place of employment: _________________________     Date hired: ____________________ 
 
Are you, or your spouse, self‐employed:  Yes____   No____ 
 
Report all other sources of income and location (Ex: Partnerships, S‐Corporation, Rental 
property, Gambling winnings, etc.):  
______________________________________________________________________________ 
 
Are you, or your spouse, retired:    Yes____  No____ Date of retirement: _____________ 
 
Person(s) in your household eighteen (18) years of age or older, including person(s) who will 
turn 18 during the calendar year: 
Name: ____________________________   SSN: _______________             DOB:_____________ 
Name: ____________________________   SSN: _______________             DOB:_____________ 
 
Signature: __________________________________      Date:_________________________ 
Spouse Signature:____________________________            Phone number: _________________ 
 
Please return this form to:   City of Brunswick Income Tax Department 
  P.O. Box 0816           
  Brunswick, OH 44212 
 
Thank you for your cooperation