Income Tax Reg. Form

SPENCERVILLE VILLAGE INCOME TAX DEPT.

P O BOX 57

SPENCERVILLE, OH 45887

419-647-4171

INDIVIDUAL REGISTRATION FORM

The information provided on this form will remain confidential and be used strictly for the Village of Spencerville Income Tax files to assist in preparing forms for compliance of the Village Income Tax Ordinance. Please complete the form and return to our office within ten days of receipt. Thank you for your cooperation.

Name (Yourself and Spouse) and Address

_____________________________________________________________________________

Date you became residents of Spencerville:__________________________________________

Employer(s) Name and Address (Please list all employment)

_____________________________________________________________________________

Is Spencerville Village Income Tax Withheld by your employer?_________________________

If not currently employed please indicate status: Retired____ Disability____ Laid Off_____

Do you have rental or farm income? If so, where is rental property or farm located?

____________________________________________________________________________

Do you pay municipal income tax to another town/city? If so please give name of municipality.

____________________________________________________________________________

Other employed person(s) residing at this address. Please list their names(s) and place(s) of

employment._________________________________________________________________

____________________________________________________________________________

Are you self-employed? __________ If so, do you have employees?_____________________

Signature:_________________________________________Date:_______________________

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