City of Warren, Ohio Income Tax Division                
                      BUSINESS QUESTIONNAIRE 
                                            
       This Questionnaire must be completed and returned to this office  
Upon receipt, whether or not there is any liability for Warren City Income 
Tax (Ordinance 9126/81). 
        
BUSINESS NAME: _____________________________________________ 
                       _____________________________________________              
       ADDRESS:   _____________________________________________ 
                       _____________________________________________              
 
If all tax is being paid under another name, list name, address and account number below: 
 
    1. Date your business started (or will start ) in Warren 
        ________________________________ 
       (To set up a Courtesy Withholding account for a Warren 
       resident, proceed to question 4.) 
 
       How acquired (Check one) 
       □ New Business 
       □ Purchased 
       □ Reorganization 
       □ Other 
 
       List name of former owner, if any, below: 

       ___________________________________ 
 
    2. List actual address of your Warren business: 
            ________________________________________ 
          ________________________________________ 
      
    3. Principal business activities:__________________________ 
     
    4.  Do you have employees?  □ Yes      □ No   If yes, how many? _____ 
     
         Date you first had employees ___/___/___ 
          Approximate monthly payroll applicable to the City of Warren $_____________ 
                  (You are required to make monthly withholding payments if your liability   
                  exceeds $200.00 per month. The Warren city tax rate is 2.5 %.) 
        
    For ** COURTESY ONLY ** Address of employee:__________________________ 
        
    **If using a Payroll Service, indicate which one: _____________________________ 
     
    5. Federal Employer Identification Number: _________________________ 

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  6. Account period used: (Check one.  If fiscal, write ending date.) 
     □ Calendar year ending December 31 
     □ Fiscal year ending _____________________ 
      
  7. State whether business is: 
     □ Individual Proprietorship                         □ Partnership 
     □ Corporation                                       □ Nonprofit Corporation 
     □ Sub Chapter S Corporation                         □ LLC  (Not an individual) 
     □ Single Member LLC, filing as an Individual 
     □ Other (state type) ___________________________ 
      
  8. Name, address and Social Security Number(s) of owner, partners or officers 
      (President and Treasurer) 
       
  Name ________________________           Name __________________________ 
  Address_______________________          Address ________________________ 
  City __________________________  City ___________________________ 
  State _____________ Zip _________    State ____________ Zip ___________ 
  Title __________________________  Title ___________________________ 
        SSN __________________________  SSN ___________________________ 
 
  9. Person this office should contact concerning city tax matters. (Do not list outside  
      Accountants.) 
  
        Name __________________________   Phone ___________________________ 
                                               Fax ___________________________ 
 
     I CERTIFY THE ABOVE INFORMATION IS TRUE AND CORRECT: 
 
NAME (Type or print) _____________________________ 
 
SIGNATURE ______________________________________   DATE ____________ 
 
TITLE __________________________________      PHONE NO. _______________ 
 
THIS DEPARTMENT MUST BE NOTIFIED OF ANY CHANGES IN ADDRESS, 
OWNERSHIP, OR TERMINATION OF BUSINESS. 
 
IF YOU HAVE ANY QUESTIONS CONCERNING THIS QUESTIONNAIRE, 
PLEASE CALL 330- 841-2624 OR FAX US AT 330-841-2626.  ALL FORMS ARE 
LISTED ON OUR WEB SITE AT www.Warren.org.  THANK YOU FOR YOUR 
COOPERATION. 
                          CITY OF WARREN, OHIO 
                           INCOME TAX DIVISION 
                                 PO BOX 230 
                            WARREN, OHIO  44482 

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