CITY OF BROOK PARK INDIVIDUAL QUESTIONNAIRE 

1. NAME __________________________________________________________________________
         FIRST, MIDDLE, LAST  

2. SPOUSE’S FIRST NAME AND MIDDLE INITIAL___________________________________________

3. YOUR BIRTHDATE_________________ SPOUSE’S BIRTHDATE_____________________________

4. ADDRESS____________________________________________________________________________

5. NUMBER OF YEARS AT THIS ADDRESS_________ IF APPLICABLE DATE RETIRED__________

6. YOUR SS#________________________SPOUSE’S SS#_______________________________________

7. TELEPHONE NO.__________________MOVE IN OR MOVE OUT DATE_______________________

8. IF YOU HAVE FILED A BROOK PARK TAX RETURN BEFORE, UNDER WHAT
   NAME____________________________ ADDRESS__________________________________________
   ACCOUNT NO. (IF KNOWN)____________________

9. NAME & ADDRESS OF PRESENT EMPLOYER____________________________________________
   SPOUSE’S EMPLOYER_________________________________________________________________
   DO PRESENT EMPLOYERS WITHHOLD CITY INCOME TAX?______YES______NO

10. DO YOU OR YOUR SPOUSE HAVE INCOME FROM SELF-EMPLOYMENT OR RENTAL
   PROPERTY _______YES________NO
   IS YOUR RENTAL INCOME IN EXCESS OF $125.00 PER MONTH_______YES_______NO
   10A.  NAME OF BROOK PARK TENANTS:________________________________________________

11. DO YOU RENT YOUR PLACE OF RESIDENCE?_______ IF YES INDICATE AN ADDRESS OF
   THE OWNER OF YOUR RENTAL PROPERTY_________________________________________

12. DOES ANY OTHER EMPLOYED PERSON RESIDE AT YOUR ADDRESS_________IF YES
   LIST PERSON/S NAME, SS#, AGE AND PLACE OF EMPLOYMENT______________________
   _________________________________________________________________________________

13. ADDITIONAL HOUSEHOLD MEMBERS
   NAME             RELATIONSHIP             SS#        DATE OF BIRTH 

1. __________________________  _____________________ ______________ _______________________
2. __________________________  _____________________ ______________ _______________________
3. __________________________  _____________________ ______________ _______________________
4. __________________________  _____________________ ______________ _______________________

I HEREBY CERTIFY THAT ALL INFORMATION AND STATEMENTS HEREIN ARE TRUE AND 
CORRECT. 

  SIGNATURE________________________________ DATE___________________________________ 

ALL INFORMATION PROVIDED ON THIS FORM IS CONFIDENTIAL AND USED FOR CITY INCOME 
TAX PURPOSES ONLY. 
PLEASE SIGN AND DATE THIS DOCUMENT: City of Brook Park    Fax (216) 433-0822 
SUBMIT VIA REGULAR MAIL, FAX,       Tax Dept.
OR THE GREEN DEPOSITORY BOX         6161 Engle Rd
OUTSIDE CITY HALL                   Brook Park, OH 44142
   FAILURE TO RETURN A COMPLETED FORM WILL SUBJECT YOU TO A MINIMUM $25 
                 PENALITY.  (CHAPTER 1705.03 DUTY TO REGISTER)