CITY OF LORAIN INCOME TAX DEPARTMENT 
                                   TH
                        605 WEST 4  STREET, LORAIN OH 44052 INCOMETAX@CITYOFLORAIN.ORG 

                             PHONE (440) 204-1002   BUSINESS REGISTRATIONFAX (440) 204-1006         
                                                   Lorain City Income Tax Rate 2.5% 

Company Name:___________________________________                          SSN or Fed ID#___________________________ 
DBA or 
Trade Name:______________________________________                         Date Started or Acquired 
                                                                           in Lorain:_______________________________ 

Lorain Address:____________________________________                       Lorain Phone:___________________________ 

                    ____________________________________                  Lorain Fax:______________________________ 

E-mail Address:____________________________________ 

Address of Main Office:_____________________________                      Phone: (          )___________________________ 

E-mail Address For_________________________________                       Accounting Period Used: 
Net Profit Accounts:                                                      Calendar Year_________      FYE Month______ 

E-mail Address For_________________________________                       Number of Persons Employed in Lorain:______ 
Withholding Accounts: 

OR:                             Payroll Service (no forms will be sent) 

Type of Ownership:              Corporation           Partnership           1120S          Individual           Non-Profit 

                         Other:___________________________________________________________ 

Complete The Following Information For All Partners, Officers And/or Associates: 

       Name:  ____________________________________________                                    SSN#:  __________________________ 
       Address:  __________________________________________   

       Name:  ____________________________________________                                    SSN#:     _________________________ 
       Address:   __________________________________________ 

If The Lorain Location Is Rented Or Leased, Please Provide Name, Address & Phone Of Rental Owner: 
Name:  ___________________________________________________                                    Phone:  __________________________ 

Address:   _________________________________________________ 

_______________________________________                   _________________________________        _____________ 
Signature                                                 Print Name                               Date 

 **ALL INFORMATION ON THIS FORM IS CONFIDENTIAL AND IS USED FOR CITY INCOME TAX PURPOSES ONLY** 

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