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._________________________ 
 
Zip Code: ____________       City: ______________________________         State: ________________ 
 
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: ________________________________________________________________