Declaration Of Exemption Business Only - City Of Dublin

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______________________
DECLARATION OF EXEMPTION
BUSINESS ONLY
This exemption form may not be used by individuals who live in the City
of Dublin or those individuals required to file a City of Dublin Individual
Income Tax form.
FID# ___________________
COMPANY NAME: __________________________________________________________________
LOCAL DUBLIN ADDRESS: _________________________________________________________
CITY: ____________________________________ STATE: _________________________________
PHONE NUMBER: (_______) __________________ FAX: (________) ________________________
CHECK THE APPROPRIATE LINE
1. No business was conducted in the City of Dublin in any part of the requested tax year. ________
2. The Company is a courtesy withholding account only ____________________________________
3. We ceased operations in the City of Dublin on (give date) _________________________________
4. Other_____________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
____________________________________________
Signature
_____________________________________________________
Title
___________________________________________________________________
Corporate Address (if different from local address
___________________________________________________________________
___________________________________________________________________
Phone number
RETURN EXEMPTION FORM TO:
City of Dublin PO BOX 9062, DUBLIN OH 43017-0962
w

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