COSHOCTON COUNTY AUDITOR
GRANT K. DAUGHERTY
349 MAIN STREET
COSHOCTON, OH 43812
740-622-1243

CITY INCOME TAX LIABILITY

NAME _______________________________    S.S. NUMBER ______________

DATE OF BIRTH                     

RESIDENCE (CHECK ONE)
                                        WITHIN COSHOCTON CORP LIMITS

                                        OUTSIDE CITY LIMITS 

OFFICE LOCATION (CHECK ONE)
                                        WITHIN COSHOCTON CORP LIMITS

                                        OUTSIDE CITY LIMITS

JOB DUTIES PERFORMED (CHECK ONE)
                                        WITHIN COSHOCTON CORP LIMITS

                                        OUTSIDE CITY LIMITS

DO YOU RESIDE IN A CITY WHERE YOU HAVE TO PAY ADDITIONAL CITY TAXES?
IF SO, PLEASE LIST THE CITY   ________________________________

DO YOU RESIDE IN A SCHOOL DISTRICT THAT REQUIRES A SCHOOL DISTRICT INCOME TAX TO BE WITHHELD?   
IF SO, NAME OF SCHOOL DISTRICT _____________________________

______________________________                 __________________
SIGNATURE                                   DATE