City of Mansfield 
                                                   Income Tax Division 
                                       P.O. Box 577 Mansfield, OH 44901 
                                       Phone: 419-755-9711   Fax: 419-755-9751 
                                               www.ci.mansfield.oh.us 

                                           INDIVIDUAL QUESTIONNAIRE 

For the purpose of our records, with regard to Mansfield Income Tax, please complete and return this 
Questionnaire promptly.  

1. Name:  _______________________________________ Phone Number: ________________________
   Social Security Number:  _______ - _______ - ________ Date of Birth: __________________________
   Street Address: ____________________________________________________
   City:  _____________________________   State    ______________________   Zip _________

2. Spouse’s Name:  ________________________________ Phone Number : _______________________
   Social Security Number:  _______ - _______ - _________ Date of Birth: _________________________

3. Date moved into Mansfield: ______________________________________________________________

4. Do you:   Own  Rent
5. If renting, provide landlord information:
   Name:  ______________________________________________
   Street Address: ____________________________________________________
   City:  _____________________________   State    ______________________   Zip _________

6. Do you own rental property?   Yes                No n

   Address of rental property.  (If more than one, please provide listing on separate page).

   Street Address: ___________________________________________________

   City ________________________________ State ______________________

7. Are you self-employed?   Yes              No                   (If yes list name and address of business).
   Business Name:  ______________________________________________
   Street Address: ____________________________________________________
   City:  _____________________________   State   ______________________   Zip _________

   Employees?  Yes                  No      (If yes please provide your Federal  Employer Identification Number). 
   FEIN :   __________________________ 

 8. List all other persons in the household Eighteen (18) years of age or older: 
 
    Name:  _______________________________________ Phone Number: ________________________ 
        Social Security Number:  _______ - _______ - ________ Date of Birth: __________________________ 
     
    Name:  _______________________________________ Phone Number: ________________________ 
        Social Security Number:  _______ - _______ - ________ Date of Birth: __________________________ 
         
    Name:  _______________________________________ Phone Number: ________________________ 
        Social Security Number:  _______ - _______ - ________ Date of Birth: __________________________ 
 
    Name:  _______________________________________ Phone Number: ________________________ 
        Social Security Number:  _______ - _______ - ________ Date of Birth: __________________________ 
 
Please mail the completed form to the address on the front page.  Form may be faxed to 419-755-9751. 
 
Mansfield tax ordinance requires any individual 18 years of age or older, domiciled in or whose usual place of abode is 
in the City of Mansfield for any portion of the tax year, to file on or before the filing deadline an annual income tax  
return.  This is a requirement even if no tax is due.