Questionnaire

Division of Taxation

City of Sylvania, 6730 Monroe St, Sylvania OH 43560-1949

Phone: (419) 885-8940 Fax: (419) 885-3442

Please provide your business name, address and phone number:

Name: ________________________________________________________________________________________

Address: ______________________________________________________________________________________

City: __________________________ State: _____ Zip Code: __________ Phone Number: _________________

The information contained on this form is necessary to open any city tax accounts needed by your company. A response is required within five (5) days. Sylvania city income tax rates are 1 ½% for payroll withholding and net profit taxes.

ALL INFORMATION IS CONFIDENTIAL PER THE SYLVANIA CITY ORDINANCES, SECTION 171.09 (d).

Check classification of business: LLC _____ LLP _____ Sub S _____ Corporation _____ Partnership _____ Proprietorship _____

List name and address of owners: __________________________________________________________________

______________________________________________________________________________________________

Federal I.D. number: ____________________________

A Social Security number is needed if you will be filing a Federal Schedule C: _____________________________

Type of work performed: _________________________________________________________________________

Will you have sub-contractors? _____ If yes, please provide a list of their names and addresses.

Date operation started in Sylvania: _________________ Date business year ends: ____________________

Address of Sylvania business location: _______________________________________________________________

Are there now or will there be employees subject to Sylvania income tax: ___________ If so, please show the payroll starting date: _______________

Check the reason for the payroll: Work performed inside city limits _____ Courtesy for Sylvania residents _____

Trade name: ___________________________________________________________________________________

Is this business an outgrowth of another business? __________ If so, please provide the names of the business & owners: _______________________________________________________________________________________

______________________________________________________________________________________________

If the address to mail tax forms is different from the address shown above, please provide the correct information: ______________________________________________________________________________________________

Name, address & phone number of the person who prepares your tax forms: _________________________________

______________________________________________________________________________________________

By signing this form, I give the Sylvania tax office permission to contact my accountant.

I CERTIFY THE ABOVE TO BE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

Signed: _________________________________ Title: ______________________________ Date: ______________