CITY OF AMHERST, OHIO 
                                                          INCOME TAX DEPARTMENT 
                                                          480 Park Avenue     Amherst, OH    44001-2258 
                                                          Phone (440) 988-4212       Fax (440) 988-3749          
                                                           Email:  incometax@amherstohio.org 
                                                                                                                                                                                                   Richard S. Ramsey 
                                                                                                                                                                                                          Treasurer 
1.  Name: ______________________________________________________________        SSN ____________________________ 
 
2.  Spouse’s Name: _____________________________________________________       SSN ____________________________ 
 
3.  Address: ___________________________________________________________        Apt #. ________ 
 
4.  Phone: (           ) ________________________       Date Moved Into Current Location: _____/_____/_____ 
 
5.  Previous address if located in the city: ____________________________________________________ 
 
6.  Do you own your place of residence in the city of Amherst?    _______ Yes           _______ No      
 
          If renting, please give the name and address of owner        __________________________________________________ 

                                                                                                                              __________________________________________________ 
7. Do you or your spouse own rental property?            _______ Yes              _______ No 
 
8.  Email Address:  ______________________________________                                                                                                     
 
9.  Give name, SSN and DOB of all others residing at this address: 
 
                                                     NAME                                                                          SSN                                                             DOB 

10.  If you or your spouse are not employed, please complete the grid below by checking the appropriate box. 
                                                      
                  Name                                     Retired  – No                                             Disabled  –No 
                                                           Earned Income                                             Earned Income 
                                                                                                                    
                By signing this form, I acknowledge that all statements are true to the best of my knowledge.  I also acknowledge 
        that I have received a copy of “Tax Information for Amherst City Residents.” 
                                                                                                                  
                                                                                                                    ________________________________________________________ 
                                                                                                                       Signature                                                             Date 
                All information provided on this form is confidential and is used for city income tax purposes only.                    Rev 10-22