Fillable TAX FILING EXEMPTION AFFIDAVIT (Port of Richmond)

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TAX FILING EXEMPTION AFFIDAVIT (Port of Richmond)

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BROWSE PORT OF RICHMOND (VIRGINIA) FORMS

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Rev. 02/10
Name
SSN
Birth Date
ID Verified
Processed Date
TAX FILING EXEMPTION AFFIDAVIT
please type or print in ink
Address
This is to certify to the Richmond Retirement System that I was not required to file federal and/or state tax returns fo
r
the year ended __________________________________.
I, ______________________________________________, being duly sworn, deposes and says as follows:
PART A - PERSONAL DATA
PART B - AFFIANT
PART C - NOTARY PUBLIC
Signature of Affiant Date
Reviewed Date
Processed By
State of __________ City/County of __________
Reviewed By
The foregoing instrument was acknowledged before me this _____ day of __________, 20_____ by
____________________________________________ (name of person seeking acknowledgment)
Notary Signature ______________________________
Notary Registration Number ______________________
My Commission Expires _________________________
RRS Use Onl
y
900 East Broad Street
Room 400
Richmond, VA 23219
RICHMOND RETIREMENT SYSTEM
www.richmondgov.com/retirement
Phone 804.646.5958
Fax 804.646.5299
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TAX FILING EXEMPTION AFFIDAVIT (Port of Richmond)

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Completed 1 November 2020

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