SUBCONTRACTED BUSINESS AND/OR INDIVIDUAL QUESTIONNAIRE

                                                                                                                                                                                                                                                                                                                                                                                                                                                                           BLUE ASH INCOME TAX DIVISION
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         4343 COOPER ROAD
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       BLUE ASH, OHIO 45242-5699
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         (513) 745-8516

                                                                                               NAME:                                                                                                                                                                                             ___________________________________________________________________________________
                                                                                               STREET:                                                                                                                                                                                           ___________                                                                                                                                                 _____________                                                      CITY: __________________                                                                                                                                                                                                                                             STATE: _____     ZIP: _____________
                                                                                               SOCIAL SECURITY NO:                                                                                                                                                                                                                                                                  _____________________                                                                                                                                                                              FEDERAL ID NO: ___________________________________
                                                                                               DAYTIME PHONE NO:                                                                                                                                                                                                                                                                    _____________________                                                                                                                                                                              CONTACT PERSON: ________________________________
                                                                                               NATURE OF BUSINESS:                                                                                                                                                                                                                                                                  _________________________________________________________________________

                                                                                               ACCOUNTING PERIOD:                                                                                                                                                                                                                                                                                                                                            o             CALENDAR YEAR     OR                                                                                                                                                                                                                                           o  FISCAL YEAR ENDING ______________________

NAME OF COMPANY: ______________________________________________________________________________

                                                                                                                                                                                    TYPE OF BUSINESS:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      CORPORATE OFFICERS (IF APPLICABLE):

                                                                                               o                                                                                                                 SOLE PROPRIETORSHIP
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           PRESIDENT: ________________________________
                                                                                               o                                                                                                      PARTNERSHIP
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           TREASURER: _______________________________
                                                                                               o                                                                                                                 S CORPORATION

                                                                                               o                                                                                                                 CORPORATION                                                                                                                                                                                                                                                                                                                                                                                                                                                               PARTNERS (IF APPLICABLE): NAME & ADDRESS:
                                                                                               o                                                                                                                 LIMITED LIABILITY COMPANY                                                                                                                                                                                                                                                                                                                                                                                                                                                 1.                                                               ___________________  ____________________
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           2.   ___________________   ____________________
                                                                                               o                                                                                                      INDIVIDUAL

                                                                                               o                                                                                                                 STATUTORY EMPLOYEE

                                                                                               STARTING DATE OF BLUE ASH ACTIVITY:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              ___________________________________________
                                                                                               NAME AND ADDRESS OF BLUE ASH JOBSITE:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            ___________________________________________
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                ___________________________________________
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       Attach complete listing with addresses & phone numbers of
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       all subcontractors used.

                                                                                               NUMBER OF EMPLOYEES WORKING IN BLUE ASH: ___________________________________
                                                                                               HOW MANY HOURS WORKING IN BLUE ASH:  ____ PER WEEK    ____PER MONTH     ____ PER YEAR

                                                                                               I CERTIFY THE ABOVE INFORMATION TO BE TRUE, COMPLETE, AND ACCURATE.

                                                                                               SIGNATURE: ______________________________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  TITLE: __________                                                       ___                   DATE: _____________