ACCT #:   
 City of Newark           Individual Registration Form                                            Phone:      740-670-7580 
 Income Tax Division                                                                              Fax:          740-670-7581 
 PO Box 4577                                 Registering as (check one)                           Email:     citytax@newarkohio.net 
 Newark Oh  43058                                                                                 Website:   www.newarkohio.net 
                          Resident                                                Non-resident 
 Please assist us in completing your account information.  If you have any questions while completing this form, 
          please contact our office.  Mail, fax or e-mail within 10 days.  Thank you for your cooperation. 
                                                                                        
Taxpayer Name                                                                                    Social Security #                                        
Address*                                                                                                                                                  
 
*If you or your spouse have not lived at above address 7+ years, please list your addresses with dates for each for the last 7 years from most recent to 
oldest on the back of this form for each spouse (if applicable). 
 
Home Phone #                Daytime Phone #                                                      Date of Birth                                            
       Check here if we may contact you by email.  Email                                                                                                  
 
Date moved into City                                              Do you  (check one)          Own              Rent             Lease 
If you rent or lease, what is the name and address of your landlord?                                                                                      
                                                                                                                                                          
Type of Income (Please check all that apply) 
 
       Employed           Self Employed        Rental Property Owner          Retired          Disabled          Gambling Winnings        
           (W2 wages)               (Schedule C)                        (Schedule E)  
Other:                                        (Please specify) 
 
Name of Employer:                                                                                                                                         
Address of Employer:                                                                                                                                      
Is local tax being withheld? (Check one  )           Yes, name of City                                                                    No 
 
If you have not worked for the above employer 7+ years, please list all employers for the last 7 years from most recent to oldest on the back.           
For each employer include:  name of employer, address, start & end dates.  If city tax withheld, list the city that tax was withheld. 
 
Schedule C filers:  Date began business(es) in city                                                                                                       
Schedule E filers:  Date purchased rental property and location                                                                                           
 
If you have multiple rental properties, please list the purchase date and location of each property on the back of this form. 
 
Spouse Name                                                                                      Social Security #                                        
 
Daytime Phone #            Date of Birth                                                       Date moved into City                                       
       Check here if we may contact you by email.  Email                                                                                                  
 
Spouse Type of Income (Please check all that apply.) 
       Employed           Self Employed        Rental Property Owner          Retired          Disabled          Gambling Winnings        
           (W2 wages)               (Schedule C)                        (Schedule E)  
Other:                                        (Please specify) 
Name of Employer:                                                                                                                                         
Address of Employer:                                                                                                                                      
Is local tax being withheld? (Check one  )          Yes, name of City                                                                     No 
 
If you have not worked for the above employer 7+ years, please list all employers for the last 7 years from most recent to oldest on the back. 
For each employer include:  name of employer, address, start & end dates.  If city tax withheld, list the city that tax was withheld. 
 
Filing Status Requested for City Return:  (Check one)      Joint                               Married filing Separate        Single 
 
Taxpayer Signature                                                                                 Date                                                   
Spouse Signature                                                                                   Date