1 CASCADE  PLAZA – Suite 100 
  AKRON, OH 44308-1161                                                               ART P. PREIKSA 
                                                                                     TAX COMMISSIONER
  Telephone: (330) 375-2290      
   Fax: (330) 375-2112 
  Email: incometax@akronohio.gov

                                                 INCOME TAX DIVISION 
                                                 DEPARTMENT OF FINANCE 

                                 Tax Practitioner Questionnaire

  Participation in Akron's Information Sharing  Program is granted to those who we can 
  substantiate are bona fide professional tax preparers.   To aid in the qualification process 
  we ask that you complete, sign and return the following questionnaire: 

  1. What is the business name?  ______________________________________________

  2. Who is the contact person? (Person signing this form) __________________________

  3. What professional titles have you earned?____________________________________

  4. Professional affiliations?__________________________________________________

  5. Is your business located within the corporate boundaries of the City of Akron?________
   If so, how many employees do you usually have during tax season? _______________
   If an Akron or Akron-JEDD business, what is your FEIN or SS#? __________________
  6. Are you affiliated with any other tax preparation firm? __________
   If so, which one?________________________________________________________

  7. What tax software do you use?_______________________________  Do you buy their
   Akron tax software or do you use their generic Ohio city form? ____________________

  8. How do you advertise your business?   ______________________________________

  9. On which federal form do you report your income from tax preparation activity?
           † Schedule C       1065      †        1120s      † 1120     † Other†_____________________  
          (A copy of the return may be required.)       
  10. How long have you been in this business? ___________________________________

  11. How many Akron clients did you have in the most recent tax year? ________________

  12. Do you have a PTIN ?  If so, enter it here ____________________________________

  Print, date and sign a copy of this form and return it to us by mail. 
  I certify that the information provided herein is true and complete. 

  ___________________________________________________         ________________ 
   APPLICANT’S  SIGNATURE                                                      DATE 
  ___________________________________________________         ________________ 
  MAILING ADDRESS  (Include city, state and zip)                                   DAYTIME  PHONE   NUMBER 
  ___________________________________________________         ________________        
  EMAIL  ADDRESS                                                                 FAX   NUMBER 

  Upon receipt of the completed questionnaire we will determine the level of participation to 
  which you will be entitled.  You may be authorized to use our online program, or you may 
  be limited to our manual information sharing program. 

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