HomeMy WebLinkAboutTreasury Information Request 2018_201806040840444192Revised 5/9/2018
ANDY SCHOR, MAYOR LA NSING TREASURY INFORMATION REQUESTCOMPLETE A SEPARATE FORM FOR EACH INDIVIDUAL SUBJECT TO VERYIFICATION Date:
APPLICANT/EMPLOYEE INFORMATION
Name (RA):
Home Address:
Daytime Phone Number:
Social Security (last 4 digits ONLY):
Drivers License #
Date of Birth:
EMPLOYER/BUSINESS INFORMATION
Corporate Name:
Doing Business As (DBA):
Address:
Business Phone Number:
FEIN #:
Date business was established: _________________________________________
Do you, or any of these businesses, owe the City of Lansing money for any reason? Yes No
If Yes, for what reason?
Name of any other Lansing area business in which your ownership participation exceeds 25%
Signature Date
CITY OF LANSING
TREASURER'S OFFICE/INCOME TAX DIVISION
Room G-29, First Floor, City Hall
124 W Michigan Ave
Lansing, Michigan 48933
(517) 483-4121
FAX (517) 483-6084
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