Individual Declaration Of Exemption 2005 Form - City Of Lakewood
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1City of Lakewood
This exemption form may not be
Division of Municipal Income Tax
Individual
used by those engaged in business,
12805 Detroit Ave
including those receiving, self-
Lakewood, OH 44107
Declaration of Exemption
employment, Federal K-1
Telephone: (216) 529-6620
distributions or rental property
2005
Fax: (216) 529-6099
located in The City of Lakewood
The City of Lakewood currently requires mandatory filing of City tax returns. If you meet one of the following
exemptions, the filing of this Declaration of Exemption will serve to meet the filing requirement.
Social Security Number
Spouse’s Social Security Number
Last Name
First Name
Initial
Spouse’s Last Name
First Name
Initial
Present Address
Apt #
City
State
Zip Code
Please circle one of the following and attach documentation when necessary.
1. I am permanently retired as of ______ / _______ / _______
2. No taxable income for all of 2005
3. I was under 18 years of age for the entire year of 2005. Date of Birth: ______ / ______ / ______
(Please attach documentation-copy of Birth Certificate or Driver’s License)
4. Active military duty for the entire year of 2005
5. I did not reside in the City of Lakewood for any part of the year. Date moved out of Lakewood: _____ / _____ / _____
(Please attach proof of move such as lease or proof of purchase date).
6. Full time student living on campus or in off campus housing and residing in the City of Lakewood for less than sixteen
(16) consecutive weeks during the taxable year of 2005 (Please attach proof. See Instructions for acceptable
documentation).
7. I am filing jointly with my spouse_______________________ Social Security #____________________.
8. Taxpayer is deceased. Date of Death: _____ / _____ / _____. (Please attach a copy of the death certificate).
I hereby declare the information supplied above to be true, correct and complete
Signature
Date
Spouse’s Signature
Date
Telephone Number
Mail completed form to:
City of Lakewood
Division of Municipal Income Tax
12805 Detroit Ave. Lakewood, Ohio 44107
Form may be faxed: 216.529.6099
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