Individual Declaration Of Exemption - Cleveland, Ohio - 2014
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12014
CLEVELAND
REGIONAL INCOME TAX AGENCY
800-860-7482
COLUMBUS
866-721-7482
YOUNGSTOWN
866-750-7482
TDD
440-526-5332
P.O. BOX 94801
Cleveland, Ohio 44101-4801
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)
ADDRESS NUMBER
STREET NAME
CITY NAME
STATE
ZIP CODE
DAY PHONE
EVENING PHONE
I AM NOT REPORTING TAXABLE INCOME FOR 2014 BECAUSE:
1.
I had NO TAXABLE INCOME for the entire year of 2014 (Attach a copy of your Federal 1040 Form)
2.
I was a member of the ARMED FORCES, including the National Guard, of the United States for all of 2014
and had no other taxable income. (This does not include civilians employed by the military)
3.
____/____/____
I was UNDER AGE 18 for all of 2014……………………………………………………………………..... Date of Birth:
)
MO DAY YR
(Attach copy of Birth Certificate or Driver’s License. For exceptions, see special notes
4.
I am a RETIRED individual receiving only pension, social security, interest,
____/____/____
dividends or other non-taxable income for all of 2014 …………………………………………………….Date Retired:
MO DAY YR
)
(Attach a copy of page 1 of your 2014 Federal 1040 return
Prior to January 1, 2014, I moved from a RITA municipality………………………………………...........Date of Move:
5.
____/____/____
(Indicate previous address below)
MO DAY YR
__________________________________________________________________________________________
PREVIOUS ADDRESS
6.
Taxpayer is Deceased…………………………………………………………………………………………Date of Death:
____/____/____
MO DAY YR
(Please enclose copy of Death Certificate)
7.
I am filing a 2014 RITA return Jointly, with my Spouse. ______________________________________________
______-_____-_________
Spouse’s Name
Spouse’s SSN
________________________________________ ________________________________________
SIGNATURE
DATE
SPOUSE’S SIGNATURE
DATE
THE ABOVE SIGNED DECLARES THAT THIS RETURN IS TRUE, CORRECT AND COMPLETE FOR THE TAX YEAR 2014.
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