EARNED INCOME TAX DIVISION 
                                                                                           800 FRENCH ST., 8TH FLOOR 
                      City of Wilmington, Delaware                                         TELEPHONE:  (302) 576-2418 
                      City/County Building   800 French Street 19801                      FAX:  (302) 576-2577 
                                                                                           WEB ADDRESS:  www.WilmingtonDE.gov 
                                                                      
                                                         APPLICATION 
                                                                FOR 
                                                   SELF-REPORTING EMPLOYEE 
                                      EARNED INCOME TAXPAYER ACCOUNT 
                                                                 
 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 
       NUMBER         Enter Social Security Number:                                                                                                                           

                      Name:           __________________________________     Address                                                                                          
     TAXPAYER NAME    
        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                                                        ___________________________________________________ 
                                                                      ___________________________________________________ 
                                                                                                                                                                                                                                          
W:\WDOX\10115101\W0066949.DOCX        / 10/19/2016                                                              Revised: 10/19/2016