Kenyon College
City of Mount Vernon Tax Form
Name: Last, First, M.I. Social Security Number
Current Home Address (If you are in the process of moving, please provide your address at this time, then provide an update to HR one
your new address is established). List Street Address, P.O. Box if applicable, City, State, Zip.
Payroll Information: Mount Vernon City Taxes
Please check your preference in box below.
Yes, Please Withhold Tax at 1% of my taxable gross earnings as required by the City of Mount Vernon for Income Tax.
I certify that I live within the city limits and/or am a resident of the City of Mount Vernon.
No, I do not wish to participate
No, Mount Vernon City Income Taxes are not applicable to me as I do not live within Mount Vernon City Limits
City of Mount Vernon, Division of Income Tax, Mount Vernon, Ohio: Employee's Withholding Certificate
Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and believe, it is true, correct, and
complete.
Signature: Date:
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