CITY OF PICKERINGTON           
INCOME TAX       DEPARTMENT         
100 Lockville    Road    
Pickerington, OH       43147 1399‐    
Telephone: (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 SS# living    at your   address who is     18 years    of   age or   older    : 

 ___________________________________________________________________________________________ 

PRESENT ADDRESS:        ____________________________SINCE:__________________________________________                                     

PREVIOUS ADDRESS:         __________________________________________________________________________                                    

YOUR SS#:____________________________________SPOUSE SS#:_____________________________________                                            

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?       _____________________________________________