City of Lakewood 
                             Division of Municipal Income Tax 
                             12805 Detroit Ave Lakewood, OH 44107 
                             Phone (216) 529-6620 * Fax (216) 529-6099 
                                    www.lakewoodoh.gov  
                                                  
                         Business Income Tax Registration 
                         —Please Complete and Return Within Five (5) Days— 
                                                  
Business Name: ______________________________________________________________________ 
DBA: _______________________________________________________________________________ 
FEIN/FEID: _____-____________________ Nature of Business: ________________________________ 
Home Office Street Address: ____________________________________________________________ 
City: ___________________________ State: _____________________ Zip: ______________________ 
Business Phone: _________________________ Business Fax: ________________________________ 
 
If the home office is not located in Lakewood, does the business have a satellite office in Lakewood? 
Yes _____ No _____ 
 
If Yes, please list the Lakewood street address: _____________________________________________ 
 
Date you started doing business within Lakewood: _____/_____/______ 
Date you first had employees within our Lakewood: _____/_____/______ 
Approximate monthly payroll amount: $____________________ 
If you are using a payroll service, indicate which one: _________________________________________ 
 
If you would like us to mail correspondence from our office to an accounting firm or payroll service, please 
indicate below: 
 
Name: _____________________________________________ Phone: __________________________ 
Address: ____________________________________________________________________________ 
 
Account Type (Check all types applicable to you or your business): 
 
_____  C Corporation or _____ S Corporation: 
      President: ______________________________ Vice President: _________________________ 
      Subsidiary Of: _______________________________________ Fiscal Year End: ____________ 
                 
_____   Partnership - If more than three (3) partners, please attach list:  
      Name: __________________ SSN: _________________   Address: __________________ 
      Name: __________________ SSN: _________________   Address: __________________ 
      Name: __________________ SSN: _________________   Address: __________________ 
      Fiscal Year End: ____________ 
         
_____  Sole Proprietorship:  
      Name of Owner: _________________________________ SSN: ______________________ 
      Address: _____________________________________ Phone:_______________________ 
 
Withholding Account Type (Check all that apply): 
 
_____   Workplace Tax (Business  islocated in Lakewood) – 1.5% 
_____  Residence Tax/Employee Courtesy Withholding (Business   is not located in Lakewood) – 1.0% 
_____  Remote Employment (Employees work from home in Lakewood) – 1.5% 
_____  Hybrid Schedule.  Business withholds for Lakewood when employee: 
      _____  Works from home in Lakewood ONLY – 1.5% 
      _____   Works from Lakewood home AND in non-Lakewood office – 1.5% & 1.0% respectively