CITY OF WAPAKONETA 
                     INCOME TAX DEPARTMENT 
                     701 PARLETTE COURT 
                     P O BOX 269 
                     WAPAKONETA, OHIO 45895 
                     (419) 738-7342   Phone 
                     (419) 738-4762   Fax 
 
                     INDIVIDUAL QUESTIONNAIRE 
 
Please complete this questionnaire and return it to the Income Tax Department.  Information provided will be 
used exclusively for income tax purposes and will not be further disclosed. 
 
Name __________________________________________ SS# ____________________________________ 
 
Spouse _________________________________________ SS# ____________________________________ 
 
Address _________________________________________________________________________________ 
 
Date you became a resident or property owner ___________________________________________________ 
 
List anyone else who is employed and living in the household 
 
        Name ___________________________________   SS# _____________________________________ 
 
        Name ___________________________________   SS# _____________________________________ 
 
Name of your employer _____________________________________________________________________ 
 
Spouse’s employer _________________________________________________________________________ 
 
Is your total income derived from salaries and wages:  [  ]  Yes   [  ]  No 
 
If no, please list other sources of income: _______________________________________________________ 
 
If you are not presently employed, place an “X” after the listing below which most accurately describes your 
status. 
 
        [  ]  Retired   Dated retired ___________________                   [  ]  Unemployed 
 
        [  ]  Military  Date entered ___________________                    [  ]  Government assistance 
 
        [  ]  Other  Specify ________________________________________________________________ 
 
Signature __________________________________________         Date _______________________________