Village of Evendale                EVENDALE INCOME  TAX  DEPARTMENT                        Phone  (513)563-2671 
10500 Reading Road                                                                      Fax       (513)563-4636 
Evendale, Ohio 45241                     NEW  RESIDENT QUESTIONNAIRE                       www.evendaleohio.org 

     Please note:  Name and phone number may be shared with other departments within the Village of Evendale.  

Address                                               Date moved into Village 

Your Name                                             SSN - Last 4 Digits Only 

Employer                                              Employer’s address 

Do you have earnings tax withheld?          Yes    No If so, where? 

Do you have business income?                Yes    No  If so, where? 

Spouse’s Name                                         SSN - Last 4 Digits Only 

Employer                                              Employer’s Address 

Does spouse have earnings tax withheld?     Yes    No If so, where? 

Does spouse have business income?           Yes    No If so, where? 

Note:  Please list below  allother household occupants, regardless of employment status 
 
       Name                                              SSN - Last 4 Digits Only       Age 

Do you own your home?               Yes     No 
 If you rent your home, provide name and address of Landlord 

Do you own rental property?         Yes     No 
 If so, please provide address of rental property 

I hereby certify that to the best of my knowledge the above information is true, correct and complete. 

Name                                                           Email   
(please print) 
Signature                                                      Phone Number                            Date  

Approved By                                Date                    Account Number