EARNED INCOME TAX DIVISION 
                                                                                800 FRENCH ST., 8TH FLOOR 
                     City of Wilmington, Delaware                               TELEPHONE:  (302) 576-2418 
                                                                                FAX:  (302) 571-6780 
                     City/County Building   800 French Street 19801            WEB ADDRESS:  www.WilmingtonDE.gov 

                                            APPLICATION 
                                                             FOR 
                                   SELF-REPORTING EMPLOYEE 
                                   EARNED INCOME TAXPAYER ACCOUNT 
                                                                                                     Start Date

INSTRUCTIONS:    City of Wilmington Ordinance No. 78-015, Section 30-30 provides, in part, that subject to the Earned Income Tax regulations are all: 
A. . . salaries, wages, commissions, and other compensation earned by residents of the city; (and) “ . . . by non-residents of the city for work done or services
performed or rendered by the city.@
 Complete and submit this form to the EARNED INCOME TAX DIVISION to request establishment of an Earned Income Taxpayer Account. 

      IDENTIFICATION Enter Social Security Number:______________________________________________________________ 
      NUMBER

 TAXPAYER NAME       Name:         __________________________________   Address 
      AND ADDRESS* 
                                   __________________________________ 
      *See 1 Below
                     Telephone Nos: _____________________________ 

 CURRENT EMPLOYER    Name:         __________________________________   Address 
 NAME AND ADDRESS* 
                                   __________________________________ 
      *See 2 Below
                                    __________________________________ 

OTHER MAILING ADDRESS

            DATE                   TYPED OR PRINTED NAME                            SIGNATURE 

            If you have lived at your present address less than 
            3 years, please provide your previous address.           _________________________________________________ 
 1. PREVIOUS
 ADDRESS
                                                                       _________________________________________________ 

                If you have worked for your present employer 
            less than 3 years, please provide your previous            ___________________________________________________ 
 2.PREVIOUS     employers=name and address. 
 EMPLOYER                                                            ___________________________________________________ 
                                                                     ___________________________________________________ 

\\CITY-WORLDOX\WORDPROCESSING\WDOX\10115101\W0066949.DOCX / 11/14/2019                               Revised: 11/14/2019