City of Englewood Income Tax Department                     INDIVIDUAL QUESTIONNAIRE 
333 W National Rd, Englewood OH  45322                                                                   
Phone (937) 836-5106   Fax (937) 771-2891                                       ENGLEWOOD TAX RATE 1.75%
Email:  tax@englewood.oh.us 
Website:  www.englewood.oh.us 
                                                            All information remains strictly confidential 
 
                                          TAXPAYER #1
Name_______________________________________        Name of Employer _____________________________ 

Address _____________________________________      Is Local Tax being withheld? 

SSN________________                                Yes_____ City Withheld ________________No_____ 

                                                   Do you have Schedule C income? 
Date of Birth ______________ 
                                                   Business Name _____________________________ 
Contact Phone _____________________ 
                                                   Federal ID________________ 
Email: ___________________________ 
                                                   Date business began in Englewood _______________ 
May we use this email to contact you? YES___ NO___ 
                                                   Do you have employees?  Yes _____ No ______ 
Date moved into Englewood_______________ 
 
                                          TAXPAYER #2 
Name_______________________________________        Name of Employer _____________________________ 

Address _____________________________________      Is Local Tax being withheld? 

SSN________________                                Yes_____ City Withheld ________________No_____ 

                                                   Do you have Schedule C income? 
Date of Birth ______________ 
                                                   Business Name _____________________________ 
Contact Phone _____________________ 
                                                   Federal ID________________ 
Email: ___________________________ 
                                                   Date business began in Englewood _______________ 
May we use this email to contact you? YES___ NO___ 
                                                   Do you have employees?  Yes _____ No ______ 
Date moved into Englewood_______________ 
 
Names, Social Security Number and Date of Birth of other members of the household over the age of 18: 
Name_______________________________________________   SSN ___________________ DOB ______________   
Name_______________________________________________   SSN ___________________ DOB ______________   
 
Taxpayer Signature ________________________________________    Date ____________________ 
 
Spouse Signature __________________________________________ Date ____________________