Zip Code Zip Code

SSN: (         ) Date
Mail worksheet to:                
Cincinnati OH  45202-5799
Cincinnati Income Tax Division  805 Central Avenue Suite 600 
NO
Work Phone:

 $
Street Address/City/State
Name of Employer/Income Source YES

Date To Present Date To Present
(        ) NO

YES

Spouse's Name: Home Phone: RESIDENTIAL ADDRESSES (Complete worksheet for the past six years) Date From EMPLOYMENT/INCOME HISTORY (Complete worksheet for past six years) Date From SIGNATURE--I certify that the above information is true and accurate. Spouse's Name

Zip Code Zip Code
What do you collect monthly for rent from the property?
NO

SSN: (         ) To Date
TAXPAYER INFORMATION WORKSHEET
CITY OF CINCINNATI INCOME TAX DIVISION YES

Work Phone:

From
Street Address/City/State

Name of Employer/Income Source

Date To Present Date To Present
(        )

Your Name: Home Phone: RESIDENTIAL ADDRESSES (Complete worksheet for the past six years) Date From EMPLOYMENT/INCOME HISTORY (Complete worksheet for past six years) Date From SUPPLEMENTAL INFORMATION: 1)  Do you and/or your spouse receive Form K-1 income from a partnership or an S-Corporation? (circle option)  2)  Do you own rental property? (circle option) 3)  If YES, what was the date of purchase? 4)  Have you or your spouse been self-employed within the past six years? (circle option) 5)  If YES, provide specific dates: SIGNATURE--I certify that the above information is true and accurate. Your Name