CITY OF  PICKERINGTON         
INCOME TAX       DEPARTMENT         
100 Lockville    Road    
Pickerington, Ohio     43147    
Phone: (614)     837 4116‐  
Fax: (614)  833   2201‐   
                                                                                                                                         
INDIVIDUAL QUESTIONNAIRE                  
(MANDATORY REGISTRATION)              
 
The information requested      on   this form    is essential   to maintaining   accurate records in the tax   office and will be      
held   in strict confidence. Thank   you for your    prompt       cooperation.        
 
Please print name,     including  spouse,  as official    account  should   appear.        
 
NAME: _________________________________________HOME                              PHONE:    ________________________________              

SPOUSE: ____________________________________________________________________________________                                            

List any other   person  and their SSN   living  at your   address who is           18 years of   age or   older : 

___________________________________________________________________________________________ 

PRESENT ADDRESS:        ____________________________SINCE:__________________________________________                                     

PREVIOUS ADDRESS:        __________________________________________________________________________                                     

YOUR SSN:___________________________________SPOUSE SSN:_____________________________________                                            

YOUR EMPLOYER: _____________________________OCCUPATION:____________________________________                                              

ADDRESS: ____________________________________WORK                               PHONE:  __________________________________              

SPOUSE’S EMPLOYER:         __________________________OCCUPATION:____________________________________                                     

ADDRESS: ____________________________________WORK                               PHONE:  __________________________________              

If retired, indicate date  of   retirement: ______ Is   retirement only          source of income?    _______________________           

Do you have       rental income   ? _________       If   so, give location: ___________________________________________                  

Do you have      other income? __________        If so,   give source: ____________________________________________                      

Are you  renting  your  home?   __________       or buying?       _________ (Please  check one)           

If  renting, give name    and  address   of              landlord. If   buying, give name of            Realtor and   Realty Company   : 

___________________________________________________________________________________________ 

Do you pay   city income   tax to your   city of employment?       _____________________________________________