I, ______, Request That the SCHOOL DISTRICT TAX Checked Below Be Deducted from My Biweekly

I, ______, request that the CITY TAX CODE checked below be deducted from my biweekly salary effective ______.

* denotes new cities

_____391003 Akron City _____391007 Amberly Village _____391010 Anna _____391013 Arcanum _____391018 Ashtabula City * _____391019 Athens _____391024 Baltimore _____391025 Barberton _____391035 Bellefontaine _____391042 Bexley _____391051 Bradford _____391054 Bratenahl _____391055 Brecksville City _____391059 Broadview Heights _____391060 Brookpark _____391063 Brookville _____391064 Brunswick City (Medina) _____391074 Canal Winchester City _____391076 Canton City _____391079 Carlisle 01 _____391081 Cedarville _____391084 Centerville _____391087 Cheviot City (Hamilton) _____391088 Chillicothe _____391089 Cincinnati _____391090 Circleville City (Picaway) * _____391606 Clayton City _____391092 Cleveland City _____391097 Columbiana _____391098 Columbus City _____391103 Covington _____391105 Crestline City (Crawford) _____391106 Crooksville Village (Perry) _____391112 Dayton _____391115 Degraff Village _____391116 Delaware _____391130 Eaton _____391136 Englewood _____391137 Euclid _____391138 Evendale _____391139 Fairborn City Greene _____391141 Fairfield _____391144 Fairview Park _____391145 Farmersville Village _____391150 Forest Park City (Hamilton) _____391154 Franklin _____391157 Gahanna _____391160 Gallipolis Village _____391169 Germantown Village _____391171 Girard _____391175 Golf Manor Village _____391180 Granville Village _____391185 Greenville _____391187 Grove City _____391188 Groveport Village _____391189 Hamilton _____391192 Hartville Village (Stark) _____391194 Heath City _____391198 Hilliard _____391199 Hillsboro _____391204 Hubbard _____391205 Huber Heights _____391206 Hudson City (Summit) * _____391213 Jamestown Village _____391215 Jeffersonville Village _____391217 Johnstown City (Licking) _____391219 Kent City (Portage) _____391221 Kettering _____391227 Lakewood City (Cuyahoga) _____391228 Lancaster _____391229 Lebanon _____391232 Lewisburg Village _____391235 Lima City (Allen) _____391239 Lithopolis Village (Fairfield) * _____391242 London _____391247 Loveland _____391248 Lowellville Village _____391257 Mansfield _____391259 Maple Hts (Cuyahoga) _____391265 Marysville _____391266 Mason _____391268 Maumee City (Lucas) _____391274 McDonald Village _____391276 Mechanicsburg Village _____391280 Miamisburg _____391282 Middleburg Heights _____391285 Middletown _____391294 Minster Village (Auglaize) _____391530 Monroe City (Butler) * _____391299 Moraine _____391305 Mt. Healthy City (Hamilton) _____391307 Mt. Sterling Village _____391316 New Carlisle _____391319 New Lebanon Village _____391325 Newark _____391328 Newton Falls _____391330 Niles _____391335 North Olmsted _____391344 Norwood City (Hamilton) _____391346 Oakwood _____391348 Oberlin (Lorain) City _____391354 Oregon City _____391363 Parma _____391364 Parma Heights _____391371 Phillpsburg _____391372 Pickerington _____391374 Piqua _____391381 Powhatan Point Village (Belmont) _____391385 Reynoldsburg _____391391 Riverside _____391394 Rocky River City _____391403 Salem _____391411 Shaker Heights _____391412 Sharonville City _____391413 Shawnee Hills Village (Delaware) _____391419 Sidney _____391425 South Bloomfield Village _____391426 South Charleston Village _____391427 South Euclid City (Cuyahoga) * _____391432 Springboro _____391433 Springdale _____391434 Springfield City _____391541 Springfield-Beckley * _____391401 St Mary’s City (Auglize) _____391402 St Paris Village _____391440 Strongville _____391445 Sunbury Village (Delaware) _____391452 Tipp City _____391453 Toledo City _____391455 Toronto (Jefferson) _____391457 Trotwood _____391458 Troy _____391818 Union City (Montgomery) _____391464 Upper Arlington _____391466 Urbana _____391472 Vandalia _____391478 Wapakoneta _____391479 Warren _____391481 Washington C.H. _____391487 West Alexandria Village _____391488 West Carrollton _____391489 West Jefferson Village _____391491 West Milton Village _____391562 West Salem Village (Wayne) * _____391495 Westlake City (Cuyahoga) _____391493 Westerville _____391497 Whitehall City _____391505 Wilmington _____391513 Wyoming City (Hamilton) _____391514 Xenia _____391515 Yellow Springs Village _____391516 Youngstown City

______Signature Social Security Number

______Work Location Date