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