CITY OF AMHERST, OHIO 
                                                             INCOME TAX DEPARTMENT 
                                                             480 Park Avenue     Amherst, OH    44001-2258 
                                                              Phone (440) 988-4212       Fax (440) 988-3749          
                                                               Email:  incometax@amherstohio.org 
                                                                                                                                                Richard S. Ramsey 
                                                                                                                                                       Treasurer                              
 
1.  Name: ______________________________________________________________      SS# _______________________ 
 
2.  Spouse’s Name: _____________________________________________________       SS# _______________________ 
 
3.  Address: ___________________________________________________________        Apt #. ________ 
 
4.  Phone: (           ) ________________________       Date Moved Into Current Location: ____________ 
 
5.  Previous address if located in the city: ____________________________________________________ 
 
6.  Do you own your place of residence in the city of Amherst?    _______ Yes           _______ No      
 
          If renting, please give the name and address of owner __________________________________________________ 
 
7.  Email Address:  ______________________________________                                                                                                     
 
8.  Give name, birth date and SS# of all others residing at this address: 
 
 Name                                                                   SS#                                         DOB                     
________________________________                               __________________                                   ___________            
________________________________                                _________________                                   ___________ 
________________________________                                _________________                                   ___________             
________________________________                                _________________                                   ___________    
________________________________                                _________________                                   ___________            
 
9.  If you or your spouse is not employed, please place a date in front of the statement that most accurately describes  
     your status:   
                                                             Yourself                Spouse                                                                                                
               Retired Since                     _____________  ____________                 
               Disabled Since                   _____________  ____________         
 
10. How would you like to file your city tax return?           _______ Jointly         _______ Separately 
      (This does not have to match the federal filing status) 
11. Do you or your spouse have income from self-employment?           _______ Yes         _______ No 
 
       If yes, give the name and address of the business ______________________________________ Fed. ID# ____________ 
                                                                                        ______________________________________                                                               
12. Do you or your spouse own rental property?            _______ Yes              _______ No 
   
           By signing this form, I acknowledge that all statements are true to the best of my knowledge.  I also acknowledge 
                       that I have received a copy of “Tax Information for Amherst City Residents.” 
  
                                                                  ________________________________________________________ 
                                                                     Signature                                                             Date 
                    
                     All information provided on this form is confidential and is used for city income tax purposes only.                                                                   
 
                                                                                                                                                                                            Rev 10-19