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                                                                    INDIVIDUAL INCOME TAX 
   CITY OF KETTERING - INCOME TAX DIVISION                                             QUESTIONNAIRE 
        P.O. Box 293100 •    Kettering, OH 45429                                           
   Phone: 937.296.2502 • Fax: 937.296.3242                 Date:                                                               
                 www.ketteringoh.org                                                       
                                                           Kettering Account Number:                                           
 
Please  complete  this  income  tax  questionnaire  and  return  it  to  our  office  by  the  due  date  stated  above.  You  may  mail  or  fax  your 
completed questionnaire to our office. Please contact us if you have any questions. Forms and additional information may be obtained by 
visiting our website. Note: The City of Kettering has a mandatory filing requirement which means that all residents of the City of 
Kettering 18 years of age and older must file an income tax return with the city on an annual basis. 
 
Taxpayer:                                                           SSN#                                DOB:                         
Spouse:                                                             SSN#                                DOB:                         
Current Address:                                                    City, ST, Zip                                                    
Home Telephone #:                                                   Work Telephone #:                                                
Email Address:                                                      Cell Phone #:                                                    
Date Moved to Current Address:                                      Former Address:                                                  
Do you:   Own or          Rent your home in Kettering?                                                                               
Taxpayer Employer:                                                                                                                   
Employer Address:                                                                                                                    
Date began employment:                                              Date terminated employment:                                      
Does your employer withhold city tax?                               If Yes, for what city?                                           
 
Spouse Employer:                                                                                                                     
Employer Address:                                                                                                                    
Date began employment:                                              Date terminated employment:                                      
Does your employer withhold city tax?                               If yes, for what city?                                           
 
Are you Self-Employed? If yes, please complete the following: 
Business Name / Type of Business:                                                                                                    
Business Address / Date Business started:                                                                                            
Do you have employees?                                         If yes, please enter Federal ID Number:                               
 
Do you own Rental Property?               If yes, please provide a full listing of all rental properties. You may attach a separate 
sheet to this questionnaire or use the rental questionnaire available on our website. 
 
Do you have income from other sources, such as partnerships, estates, trusts, Form(s) 1099-Misc., or gambling winnings, etc.?         
If yes, please explain:                                                                                                              
 
Other members in your household 18 years of age and older: 
Name:                                                               SSN#                                  DOB:                       
Name:                                                               SSN#                                  DOB:                       
 
Are you eligible to file for an exemption from the City of Kettering's mandatory filing requirement? If yes, please explain:  
                                                                                                                  
Taxpayer Signature:                                                                                     Date:                        
Spouse Signature:                                                                                       Date: