ACCT #___________

VILLAGE OF MARIEMONT NEW RESIDENT
EARNINGS TAX QUESTIONNAIRE

Your Name___________________________________________________SS#______________________________

Spouse’s Name________________________________________________SS#______________________________

Address_____________________________________________________________Phone #____________________

Move-In Date__________________________________E-mail___________________________________________

If you rent, give name and address of landlord: ________________________________________________________

______________________________________________________________________________________________

EMPLOYMENT INFORMATION

Are You Employed?_________________Retired?_______________Date of Retirement________________________

Your Employer__________________________________________________________________________________

Address of Employer_____________________________________________________Phone #__________________

Do you pay earnings tax to another city?_________If so, what city?________________________________________

Spouse’s Employer_______________________________________________________________________________

Address of Employer_____________________________________________________Phone #__________________

Does Spouse pay earnings tax to another city?__________If so, what city?___________________________________

SELF EMPLOYED PERSONS (FULL OR PART TIME) PLEASE COMPLETE:

Owner__________________Partner_______________Other________________Number of Employees____________

Type of Business________________________________________________________Business Phone #___________

Address of Business_______________________________________________________________________________

LIST BELOW ALL OTHER OCCUPANTS OF HOUSEHOLD REGARDLESS OF EMPLOYMENT STATUS.
LIST AGES OF CHILDREN: (Use back of form if necessary)
_______________________________________________________________________________
_______________________________________________________________________________

IF YOU OR ANY MEMBER OF HOUSEHOLD OWNS RENTAL PROPERTY, COMPLETE THE FOLLOWING:

Name of Property Owner___________________________________________________________________________

Address of Rental Property__________________________________________________Date Acquired____________

_______________________________________________________________________________________________

I hereby certify that to the best of my knowledge, the above information is true and correct.

SIGNATURE___________________________________________________________DATE____________________