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                                                                                                                                                                Date Sent: 
                    CITY OF WESTERVILLE MUNICIPAL INCOME TAX REGISTRATION FORM                                                                                   
City Ordinance 94-98 requires a registration with the Income Tax Division.  All residents 18 years and older are also required to file 
an annual City of Westerville Tax Return regardless of any tax due to Westerville.  The information requested on this form will be 
used to establish your tax record.  (Persons age 17 years and under are not subject to Westerville Income Taxation).  All tax 
information is confidential. 

The current rate of tax in the City of Westerville is 2%.  However, there is credit given for taxes paid or withheld to another city (ie: 
Columbus, Gahanna, Dublin) limited to 2%.  Estimated payments will be required for individuals who anticipate a Westerville tax 
liability of $200.00 or more.  If we may assist you regarding your Income Tax, please don’t hesitate to call us at (614) 901-6420.  All 
forms and instructions are located on our website @                                                      www.westerville.org under the tab called “Services” then “Income Tax Forms”.  
Our address is P.O. Box 130 Westerville, OH  43086 

PLEASE COMPLETE THE FOLLOWING INFORMATION & RETURN THIS FORM WITHIN   DAYS FROM THE ABOVE DATE.                                   20                                  Please print 

First Name: _______________ Middle Initial: ____ Last Name: _________________ M/F: ___ DOB: _______ SS#:______________ 
Spouse: 
First Name: _______________ Middle Initial: ____ Last Name: _________________ M/F: ___ DOB: _______ SS#:______________ 

Primary Email Address: ___________________________________                                                           Primary Phone #: _______________________(Home or Cell) 

Westerville Address: ______________________________________Own/Rent: _______   Date moved into Westerville: __________ 
Your previous address: ________________________________________________________________________________________ 

If Rent – name and address of Landlord: 
___________________________________________________________________________________________________________ 
Do you own property that you rent to others?    YES/NO                                                                If so, address(s) of Rental(s):_________________________________ 
____________________________________________________________________________________________________________ 

Are you retired:    YES/NO                                                                     IF YES, Please check type of non-taxable income: Social Security Pension 
                    Interest/Dividends                                                         Worker’s Compensation Unemployment     Active Military  Earnings while under 18 

Are you currently a student with a residence somewhere else? _______If yes, please give permanent address: 
____________________________________________________________________________________________________________ 

List all other individuals that reside at present Westerville address that are 18 years or older: 

1).First Name: __________________ Middle Initial: _____ Last Name: ___________________ M/F: ____ DOB: _________ 
SS#:_______________                                                                            Primary Email Address: ________________________Phone #:_____________ (Home or Cell) 

2).First Name: __________________ Middle Initial: _____ Last Name: ___________________ M/F: ____ DOB: _________ 
SS#:_______________                                                                            Primary Email Address: ________________________Phone #:_____________ (Home or Cell) 

3).First Name: __________________ Middle Initial: _____ Last Name: ___________________ M/F: ____ DOB: _________ 
SS#:_______________                                                                            Primary Email Address: ________________________Phone #:_______________ (Home or Cell) 

4).First Name: __________________ Middle Initial: ____ Last Name: ___________________ M/F: _____ DOB: _________ 
SS#:_______________                                                                            Primary Email Address: ________________________Phone #:_______________ (Home or Cell) 

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(Rev: 11/2018)                                                                                 Signature                                              Date: