City of Warren, Ohio Income Tax Division 

                                       INDIVIDUAL QUESTIONNAIRE 
For the purpose of our records with regard to the City of Warren Income Tax, you are required to fully complete this form and return it within five (5) 
days to the City of Warren, Income Tax Division, PO Box 230, Warren, Ohio 44482.  Please type or print plainly. THE QUESTIONNAIRE MUST BE FILED 
WHETHER OR NOT THERE IS ANY LIABILITY FOR WARREN CITY INCOME TAX. 
 
    PLEASE NOTE:  ALL PERSONS WHO ARE SUBJECT TO THE TAX IMPOSED BY WARREN ORDINANCE 9126/81 MUST FILE A RETURN 
                                       WHETHER OR NOT A TAX IS DUE. THE TAX RATE IS 2.5% 
                                                                              
NAME: ____________________________________________________________________________________                                                                
 
ADDRESS:  _________________________________________________________________________________ 
 
Your Social Security No. _______________________________ 
 
Spouse Name(if applicable) _____________________________  Social Security No.______________________________ 
 
1.  Are you presently employed? □ YES □ NO                                    Spouse?                     □ YES      □ NO 
 
2.  If not employed, do you receive one of the following:      □ SSI       □ ADC               □ State Unemployment               □ Permanent Disability 
 
3.  Are you retired?            □ YES □ NO                                     Date of retirement  _______________________________________ 
 
4. Have you been employed at any time during the past five (5) years? 
 
   …….list below each employer (starting with your present or last employer) during the past five (5) years. 
 
    EMPLOYER                                                         ADDRESS                                         DATE FROM –DATE TO 
 
______________________________________________________________________________________________________________________ 
 
______________________________________________________________________________________________________________________ 
 
______________________________________________________________________________________________________________________ 
 
______________________________________________________________________________________________________________________ 
 
______________________________________________________________________________________________________________________ 
 
Has spouse been employed at any time during the past five (5) years? 
 
   …….list below each employer (starting with your present or last employer) during the past five (5) years. 
 
    EMPLOYER                                                         ADDRESS                                         DATE FROM –DATE TO 
______________________________________________________________________________________________________________________ 
 
______________________________________________________________________________________________________________________ 
 
______________________________________________________________________________________________________________________ 
 
______________________________________________________________________________________________________________________ 
 
5. List any changes in your address during the past five (5) years.  Please do not use post office boxes. 
     
    ADDRESS                           CITY                           STATE   ZIP                                DATE FROM-DATE TO 
_____________________________________________________________________________________________________________________ 
 
_____________________________________________________________________________________________________________________ 
 
_____________________________________________________________________________________________________________________ 
 
_____________________________________________________________________________________________________________________ 
 

6.  Have you been the proprietor of a business in Warren during the past five (5) years?                 □ YES  □ NO 
 
     Has spouse?                                                                                         □ YES  □ NO 
 
     If yes, list name and location of business.                                                            Date From – Date To 
 
     Self:   _______________________________________________________________________________________________________ 
 
     Spouse: _______________________________________________________________________________________________________ 
 
7.  Do you own rental property?                                                                          □ YES  □ NO 
     If yes, list locations of ALL rental property, year property acquired and amount received monthly. 
 
    ___________________________________________________________________________________________________________________ 
 
   ____________________________________________________________________________________________________________________ 
 
   ____________________________________________________________________________________________________________________ 
 
   ____________________________________________________________________________________________________________________ 
    
   ____________________________________________________________________________________________________________________ 
 
8.  Do you own or are you buying the home you live in?                                                   □ YES  □ NO 
     If no, give name and address of owner. 
 
   ____________________________________________________________________________________________________________________ 
 
9.  If you are a Warren resident, please list anyone living in your household over the age of sixteen (16) years old and who has earned income: 
 
   Name _________________________________________________________________________________ SSN _________________________ 
 
   Name _________________________________________________________________________________ SSN _________________________ 
 
   Name _________________________________________________________________________________ SSN _________________________ 
 
I CERTIFY THE INFORMATION IS TRUE AND CORRECT. 
 
Signature ________________________________________________________________________________ Date _________________________ 
 
Spouse Signature ________________________________________________________________________     Date _________________________ 
 
Daytime Phone Number ___________________________________  Evening Phone Number ____________________________________ 
 
Email __________________________________________________ 
 
If you have any questions concerning this Questionnaire, please call 330. 841.2551 or Fax 330.841.2626.  Thank you for your cooperation. 
                    
                                                          City of Warren, Ohio 
                                                          Income Tax Division 
                                                          258 E. Market St 
                                                          PO Box 230 
                                                          Warren, Ohio 44482