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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