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

    Note:  Questionnaire is to be completed by any resident business located in the Village of Evendale 
                  or any nonresident business  providing services or operating within the village. 

Corporate/Business Name 
DBA, if applicable                                       Federal ID Number 
Corporate Address                                          Corporate Phone Number 
                                                         Corporate Fax Number 
Evendale Address                                         Evendale Phone Number 
(or work site location)                                  Evendale Fax Number 

**PLEASE NOTE:  BUSINESS NAME AND CONTACT INFORMATION ONLY MAY BE SHARED WITH OTHER
                    DEPARTMENTS WITHIN THE VILLAGE OF EVENDALE (i.e. FIRE, POLICE, SERVICE DEPTS)** 
Type of Business               Sole Proprietorship          Partnership             S-Corporation
                               Corporation                  Ltd. Liability Co.      Non-Profit 

Accounting                     Calendar Year                Fiscal Year  

Names of Corporate Officers or Partners:
            Name             Street Address          City,State, Zip Code         Title 

Nature of Operations
Date operations are expected to begin in Evendale  
Number of Employees expected at Evendale location  
Date of first payroll  
Is this a courtesy withholding tax for an Evendale resident?         Yes     No 
Indicate address to which payroll forms should be mailed: 
    Evendale                   Corporate                    N/A-Payroll Service     N/A- OBG Filer 

If a resident business, is Evendale location Rented (leased)?        Yes     No 
If yes, please provide Name and Address of Landlord: 

I hereby certify that to the best of my knowledge the above information is true, correct and complete. 
Name                                                 Title                        Date    
(please print) 
Signature                                            Telephone Number 
Email address to which you would like the account number(s) sent  

Approved By             Date            Business Account                  Withholding Account