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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