SOCIAL SECURITY NUMBER SPOUSE'S SOCIAL SECURITY NUMBER
FIRST NAME M.I. LAST NAME
SPOUSE'S FIRST NAME M.I. SPOUSE'S LAST NAME (IF DIFFERENT)
STREET NAME
CITY NAME STATE ZIP CODE
DAY PHONE EVENING PHONE
REGIONAL INCOME TAX AGENCY
P.O. BOX 94801
Cleveland, Ohio 44101-4801
INDIVIDUAL DECLARATION OF EXEMPTION
800-860-7482
866-721-7482
866-750-7482
CLEVELAND
COLUMBUS
YOUNGSTOWN
TDD
440-526-5332
I believe that I am not required to file a municipal income tax return for the year shown above because:
1.
I had NO TAXABLE INCOME for the entire year. (Enclose page 1 of your Federal Form 1040)
2.
I was a member of the U. S. ARMED FORCES (including the National Guard) and had no other taxable income for all
of the tax year. (Not including civilians employed by the military)
3.
I was UNDER AGE 18 for the entire year. (Enclose a copy of your Birth Certificate or Driver's License). Date of Birth:
MM / DD / YY
4.
I am a RETIRED individual receiving only pension, social
security, interest, or dividend income.
(Enclose page 1 of your Federal Form 1040) Date Retired:
5.
Date of Move:
Prior to January 1, I MOVED from a RITA municipality. (Enclose proof of new address)
Previous Address _______________________________________________________________________________
6.
Date of Death:
Taxpayer is
DECEASED. (Enclose copy of Death Certificate)
7.
I am filing a RITA return
JOINTLY with my S
pouse and their name and social security number are indicated in
the address section at the top of the form.
Refunds can be requested by submitting a form 10A found at www.ritatohio.com
THE BELOW SIGNED DECLARES THAT THIS EXEMPTION IS TRUE, CORRECT, AND COMPLETE.
_________________________________________________________________________________
Taxpayer's Signature DATE
Tax Year ________
MM / DD / YY
MM / DD / YY
MM / DD / YY
(Please CIRCLE the number of the statement that best applies to you)
Street # and name City State Zip
_________________________________________________________________________________
Spouse's Signature DATE
CURRENT STREEET NUMBER
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