Date __________
                                                                                                                              Date __________Date __________

                                        City of Westerville
                                          City of Westerville
                                        Business Registration
                                        Business Registration
The information requested on this form is essential to the establishment of your account and will be held in strict confidence.  Please complete, 
sign and return it to the City of Westerville Income Tax Division, PO Box 130, Westerville, OH  43086-0130 within 10 days.  If you have any 
questions, please contact the Income Tax Division @ (614) 901-6420   Fax # (614) 901-6820The information requested on this form is essential to the establishment of your account and will be held in strict confidence.  Please complete, 
sign and return it to the City of Westerville Income Tax Division, PO Box 130, Westerville, OH  43086-0130 within 10 days.  If you have any 
questions, please contact the Income Tax Division @ (614) 901-6420   Fax # (614) 901-6820
Type of Organization (Please check one)
Type of Organization (Please check one)
 Corporation                Partnership    Non-Profit                                     Limited Liability Co (LLC)                               Other (Please Explain)
        Corporation        Partnership     Non-Profit                                     LimitedSingleLiabilityMemberCo (LLC)                              Other (Please Explain)
If Limited Liability Company (LLC) will partners or individuals file?
If Limited Liability Company (LLC) will partners or individuals file?
Federal ID #  _____________________________ Social Security #   ______________________________
                                                                                                                              (If Sole Proprietor)
Federal ID #  _____________________________ Social Security #   ______________________________
BusinessFederalNameID #   _____________________________ Socialdba  __________________________________________Security #   ______________________________(If Sole Proprietor)
                                                                                                                              (If Sole Proprietor)
Business NameBusiness Name                                                               dba  __________________________________________dba  __________________________________________
Address                                                                                  City                             State           Zip  _______________
AddressAddress                                                                           City      City                            State          State          Zip Zip _______________               _______________
Telephone #                                                                               Fax #
Telephone #Telephone #                                                                    Fax # Fax #
Type of Business  ________________________________________________________
Type of Business    ________________________________________________________Type of Business  ________________________________________________________
List Social Security Number and Name of Corporate Officers and/or Partners (addresses’ if partnership)
List Social Security Number and Name of Corporate Officers and/or Partners (addresses’ if partnership)List Social Security Number and Name of Corporate Officers and/or Partners (addresses’ if partnership)
Name ___________________________________                                                                     SSN ____________________________________
Name ___________________________________Name ___________________________________                             SSN ____________________________________SSN ____________________________________
Address  _________________________________                                                                   City ____________                    State                             _____ Zip _______
Address  _________________________________Address  _________________________________                         City ____________City ____________StateState_____ Zip ____________ Zip _______

Name __________________________________                                                                      SSN  ___________________________________
Name __________________________________Name __________________________________                               SSN  ___________________________________SSN  ___________________________________
Address _________________________________                                                                    City _____________ State ________ Zip ______
Address _________________________________Address _________________________________                           City _____________ State ________ Zip ______City _____________ State ________ Zip ______

Do you have a location within the City limits of Westerville          Yes                                                                  No
Do you have a location within the City limits of Westerville          YesDo you have a location within the City limits of Westerville          Yes        No        No
If yes, please give the address of Westerville Location, if not sure call  (614) 901-6420 to verify
If yes, please give the address of Westerville Location, if not sure call  (614) 901-6420 to verifyIf yes, please give the address of Westerville Location, if not sure call  (614) 901-6420 to verify
Address                                                                                                      City                           State          Zip
AddressAddress                                                                                               CityCity                          State          Zip                          State          Zip
Date operations will begin in Westerville?
Date operations will begin in Westerville?Date operations will begin in Westerville?
Number of employees at Westerville Location?
Number of employees at Westerville Location? Number of employees at Westerville Location?

                                                                                                                                                                                    (Over) (Rev 11/02)
                                                                                                                                                                                    (Over)(Over)(Over)(Rev(Rev(Rev6/11)      11/02)2)

Do you wish for your forms to be sent to another location       Yes                                                                                                                       No
Do you wish for your forms to be sent to another location       Yes                                                                                                                       No
If YES please give the address
If YES please give the address
Address ______________________________                                                                                           City ____________                                     State ______ Zip_____________
Address ______________________________                                                                                           City ____________                                     State ______ Zip_____________
Please check an appropriate box:
Please check an appropriate box:
  Employee’s work within city limits of Westerville - Withholding rate is 1.25%2.0%
  Employee’s work within city limits of Westerville - Withholding rate is 1.25% 
  Employees live in Westerville city limits and work in a non-taxing city –Withholding rate is 1.25%2.0%
  Employees live in Westerville city limits and work in a non-taxing city –Withholding rate is 1.25%
      Employees live in city limits of Westerville and work in another taxing city and you are going to courtesy withhold .30%Employees live in city limits of Westerville and work in another taxing city and you are going to courtesy 
      Employeeswithholdlive– fullin citycreditlimitsofofactualWestervilletax withheld,and work inlimitedanothertotaxing2.0%city and you are going to courtesy withhold .30%
  No employees
  No employees
IF A WITHHOLDING SERVICE IS BEING USED PLEASE PROVIDE NAME  _________________
IF A WITHHOLDING SERVICE IS BEING USED PLEASE PROVIDE NAME  _________________
Please indicate deposit frequency & if a withholding service is being used advise them to withhold 
Please indicate deposit frequency & if a withholding service is being used advise them to withhold 
      Quarterly (under 100.00/month)                                                                Monthly (over 100.00/month)                                                       Semi Monthly  (over $1,000/month)
      Quarterly (under 100.00/month)                                                                Monthly (over 100.00/month)                                                       Semi Monthly  (over $1,000/month)
If you are other than a calendar year filer, indicate the month your fiscal year ends _____________________
If you are other than a calendar year filer, indicate the month your fiscal year ends _____________________

Person to contact regarding this account                                                                       ___________________________________________
Person to contact regarding this account                                                                       ___________________________________________
Date______________________                                                                                   Phone # _____________________________________
Date______________________                                                                                   Phone # _____________________________________
Please note:   Westerville is not a pure zip code for taxing purposes, if you have any questions regarding what 
PleasetaxPleasedistrictnote:note:  youWestervilleWestervilleare in, pleaseisisnotnotcallaapureandpurezipwezipwillcodecodebeforforhappytaxingtaxingtopurposes.verifypurposes,thisIfifinformationyouyouhavehaveanyanyforquestionsquestionsyou.   Formsregardingregardingare nowwhatwhat 
taxtaxavailabledistrictdistrictonyouyouourarearewebin,in,sitepleaseplease@www.westerville.org/taxforms.aspcallcall andand wewe willwill beverifyhappythistoinformation.verify this informationForms are nowfor you.  availableFormson ourare nowweb 
available on our web site @ site @ www.westerville.org www.westerville.org/taxforms.asp

NoThankconfirmationyou for yourwillcooperation,be sent regardingplease don’tthe assignmenthesitate to callof anifaccountwe can assistnumber.you inWeanyuseway.your federal ID#.
Thank you for your cooperation, please don’t hesitate to call if we can assist you in any way.
Thank you for your cooperation, please don’t hesitate to call if we can assist you in any way.