Exemption Certificate Form - 2008
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1
2EXEMPTION CERTIFICATE
I AM REQUIRED TO FILE THIS FORM SINCE I LIVE IN A MANDATORY FILING CITY. I AM NOT REQUIRED TO PAY CITY INCOME TAX BECAUSE:
1.
4.
RETIRED, received only pension, Social Security, interest or dividend income
NO EARNED INCOME FOR THE ENTIRE YEAR 2008.
2.
AN ACTIVE MEMBER OF THE ARMED FORCES OF THE UNITED
(Public Assistance, Unemployment, SSI, etc.)
5.
STATES FOR THE ENTIRE YEAR 2008. (This does not include
BUSINESS CLOSED OR RENTAL PROPERTY SOLD
civilians employed by the military or National Guard.)
_____ / _____ / _____ (date)
3.
UNDER 18 FOR THE ENTIRE YEAR 2008.
*see reverse for exceptions
detach
CCA MUNICIPAL INCOME TAX
205 W SAINT CLAIR AVENUE
CLEVELAND, OHIO 44113-1503
Name
Social Security No.
–
–
Name of spouse if joint return
–
–
Current address
Apt. #
City
State
Zip
I AM REQUIRED TO FILE THIS FORM SINCE I LIVE IN A MANDATORY FILING CITY. I AM NOT REQUIRED TO PAY CITY INCOME TAX BECAUSE:
1.
4.
RETIRED, received only pension, Social Security, Interest or Dividend Income
NO EARNED INCOME FOR THE ENTIRE YEAR 2008.
2.
AN ACTIVE MEMBER OF THE ARMED FORCES OF THE UNITED
(Public Assistance, Unemployment, SSI, etc.)
STATES FOR THE ENTIRE YEAR 2008. (This does not include
5.
BUSINESS CLOSED OR RENTAL PROPERTY SOLD
civilians employed by the military or National Guard.)
_____ / _____ / _____ (date)
3.
UNDER 18 FOR THE ENTIRE YEAR 2008.
*see reverse for exceptions
SIGNATURE OF TAXPAYER
SIGNATURE OF SPOUSE, IF JOINT RETURN
PHONE NUMBER
DATE
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