City of Lakewood - Division of Municipal Income Tax 
                           12805 Detroit Ave., Suite 1 
                                       Lakewood, OH  44107 
                   Telephone:   (216) 529-6620  Fax:  (216) 529-6099 
                                       www.lakewoodoh.gov     
 
                   Individual Income Tax Registration 
                    (Please Complete and Return Within Five (5) Days) 

           Primary Account                                            Joint Account 
First Name: __________________________             First Name: _____________________________ 

Middle Name: ________________________              Middle Name: ___________________________ 

Last Name: __________________________              Last Name: _____________________________ 

Social Security #: _______-_____-________          Social Security #: _______-_____-________ 

Birth Date: ___________________________            Birth Date: _____________________________ 

Phone Number: (____) ______-__________             Phone Number: (____) ______-__________ 

Email Address: _______________________             Email Address: __________________________

Date moved into Lakewood: __________________________________________________________ 
 
Street Address: _____________________________________ Apt. No._________________________ 
 
City: ______________________________         State:________________        Zip Code:____________ 
 
Do you have rental income anywhere?          Yes______     No______ 
Date of Purchase: ____/____/________          
Address (attach list if more than one): _______________________________________________ 
 
Are you or your spouse self-employed?        Yes______     No______ 
 
Do you own a Partnership or S-Corporation?   Yes______     No______ 
 
Are you or your spouse retired or disabled?  Yes (Me)______           Yes (My spouse)______ 

                                             Yes (Both)______         No (Neither)______ 

I hereby certify that all information and statements herein are true and correct: 
 
Primary Signature: ______________________________________________________________ 
 
Joint Signature: ________________________________________________________________