Jeannine Hamper
                   CITY OF ASHTABULA                                                        Income Tax Specialist
                   INCOME TAX DEPARTMENT                                                     440.992.7104 
                   City Municipal Building                                            email:taxclerk@cityofashtabula.com 
                   4717 Main Ave Ste. A  Ashtabula, Ohio  44004
                 Website:   http://cityofashtabula.com      
                 Phone:  440.992.7104  
                 FAX:    440.992.7556  

                      BUSINESS REGISTRATION APPLICATION 

For the purpose of our records, with regard to Ashtabula income tax, please complete and return this form promptly. 
Firm Name :   ___________________________________________________Nature of Business:________________________ 
Doing Business As (DBA): _________________________________________________________________________________ 
Calendar year ending December 31   Y/N __Fiscal Year End Date: _________________________________________________ 
ASHTABULA Location Address:  
_______________________________________________________________________________________ 
City:  ______________________________________ State: _________________ ZIP: _________________________________ 
Mailing Address: (if different from above) ____________________________________________________________________ 
Contact Number: (___) ____-______  Type: Cell__ Office__ Home__  Alternate Phone: (___) ____-______  
Contact Person: _________________________  Email: __________________________________________________________ 

Date Operations Began in (Please check one):  ___ Ashtabula City ___ Ashtabula Township  ___ Saybrook Township  
Date: _____________  and/or Employee Withholding date: _______________ 

Federal Id Number: __________________________ or Social Security Number, if sole proprietorship: _____________________ 

Number of Employees: ________ If none, do you expect to have employees in the future? YES ___NO___ 
Do you at any time during the year employ persons who are subject to Ashtabula Income Tax and from whom you do not 
withhold the city income tax?  Yes __ (please attach a list of such persons, showing names and addresses)  No __ 

Type of Business (Please Check one):  ___ Corporation  ___ S-Corporation  ___ Partnership  ___ Sole Proprietorship 
                                      ___  LLC (single member)   ___ LLC (multiple members)  ___ LLP 

Filing Payroll Taxes (Please check one):  ___ Monthly ___ Quarterly 

Will a payroll company be filing the company’s withholding taxes? (Please check one): 
___ Yes, name of the Payroll Company ____________________________________________________________       ___ No 

Does your company lease employees? (Please check one): 
___ Yes, name of leasing company _______________________________________________________________       ___ No 

Does your company use subcontractors? (Please check one): 
___ Yes, attach a list with name, address and phone numbers of subcontractor(s)                                     ___ No 

If the current business is the successor to a pre-existing business (e.g. due to incorporation, mergers, etc…), 
please indicate the name, address and FID number of the company:__________________________________________________ 
________________________________________________________________________________________________________ 
Name and Address of Corporate Officers or Partners. Use back of form, or submit alternative documents 

COURTESY WITHHOLDING?    Yes ___NO __    If yes, you are REQUIRED to provide employee(s) 
name, ssn, and Ashtabula address.  Use back of form, or submit alternative documents.

SIGNATURE  _____________________________________    DATE  ___________________________________________________________ 

                                                      (For Tax Office Only) 
                            CITY FILE NO.________________ JEDD ACCOUNT?  ___YES   ___NO