I, _____________________________, request that the SCHOOL ...



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

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