City Of Green Exemption Certificate For Retired Individuals - 2007

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City of Green
(330) 896-6622
Income Tax Division
Fax: (330) 896-6927
Email:
Website:
Re: Exemption Certificate for Retired Individuals
TAX YEAR 2007
Due Date: April 15, 2008
As a convenience to retirees, the City of Green Income Tax Division has initiated a program which will allow
retirees who receive only non-taxable income such as: social security, pensions, dividends or interest to file
an “Exemption Certificate.”
l
In order to qualify for this exemption, please complete the form below and return it in the envelope
provided. If you or your spouse have any kind of taxable income, you are not eligible for this exemption.
l
If you sign the Exemption Certificate for Retired Individuals, and in the future, you or your spouse
earn taxable income, the Exemption Certificate will not be valid and you will be required to file
a City Tax Return.
For example: If you begin working, start a business, own rental property or receive lottery
winnings, you will be required to file a City of Green Tax Return.
l
If in the future you are required to file a City Tax Return, you must notify this office.
l
If you do not return this form, it will be your responsibility to file a City Tax Return each year.
CITY OF GREEN
Exemption Certificate for Retired Individuals
Tax Year 2007
I am completing this Exemption Certificate because I / we are retired individual(s)
receiving only non-taxable income.
I DECLARE THIS STATEMENT TO BE TRUE, CORRECT AND
COMPLETE, AND WILL IMMEDIATELY NOTIFY THE DIVISION OF TAXATION IF THE EXEMPTION BECOMES
INVALID.
Signature________________________ Date_____________ Spouse’s Signature ________________________
Please print the following information:
_____________________________________________________
_________________________________________
Name(s)
Social Security Number(s)
_____________________________________________________
Address
_________________________________________
_____________________________________________________
Daytime Phone Number
City, State, Zip
Retircert.doc

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