CITY OF MASSILLON
                                                                                                                                                                                                                                                                                                                                                                                                                                             INCOME TAX DEPARTMENT
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          P.O. BOX 910
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   MASSILLON, OHIO 44648
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        Phone(330)830-1709
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Fax(330)830-2687

                                                                                                                                                                                                                                                                                           City of Massillon Individual Questionnaire

                                                                               Please complete this questionnaire and return it to the Income Tax Department or mail to Box
                                                                               910, Massillon, Ohio 44648-0910.  Information provided will be used exclusively for income tax
                                                                               purposes and will not be further disclosed.

                                                                                                                                                                             1.  NAME______________________________                                                                                                                                                                                                                                                                                                                                   SS#______________________________

                                                                                                                                                                             2.  SPOUSE____________________________                                                                                                                                                                                                                                                                                                                                   SS#______________________________

                                                                                                                                                                             3.  ADDRESS________________________________________________________________

                                                                                                                                                                             4.  DATE YOU BECAME A RESIDENT OR PROPERTY OWNER____________________

                                                                                                                                                                             5.  LIST ANYONE ELSE WHO IS 18 YEARS OR OVER LIVING IN THE HOUSEHOLD.

                                                                                                                                                                                                                                                            NAME__________________________                                                                                                                                                                                                                                                            SS#______________________________

                                                                                                                                                                                                                                                            NAME__________________________                                                                                                                                                                                                                                                            SS#______________________________

                                                                               6.  NAME OF YOUR EMPLOYER_______________________________________________

                                                                                                                                                                                 SPOUSE’S EMPLOYER_____________________________________________________

                                                                               7.  IS YOUR TOTAL INCOME DERIVED FROM SALARIES AND WAGES  YES___NO___

                                                                                                                                                                             8.  IF THE ANSWER TO #7 IS NO, PLEASE LIST OTHER SOURCES OF INCOME.

                                                                                                                                                                                   _________________________________________________________________________

                                                                                                                                                                             9.  IF YOU ARE NOT PRESENTLY EMPLOYED, PLACE AN X AFTER THE LISTING
                                                                                    BELOW WHICH MOST ACCURATELY DESCRIBES YOUR STATUS.

                                                                                                                                                                                                                                                                     RETIRED                                                         [ ]                                                   DATE RETIRED____________                                                                                                                                                                    UNEMPLOYED      [ ]

                                                                                                                                                                                                                                                            MILITARY                                                                 [ ]                                                   DATE ENTERED___________                                                                                                                                                                     GOV. ASSISTANCE [ ]

                                                                                                                                                                                                                                                                     OTHER                                                           [ ]                                                   __________________________________________________

       SIGNATURE_____________________ DATE__________ PHONE# (____)_____-_______

       SPOUSE_________________________ DATE__________