Exemption Certificate/alternate 1040/signatures - City Of Norwalk - 2012

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Final Return
Print Alt. 1040
TAX YEAR
2012
CITY OF NORWALK
MAIL COMPLETED FORMS TO:
SECTION 1: EXEMPTION CERTIFICATE
INCOME TAX DEPARTMENT
NORWALK CITY INCOME TAX DEPT.
38 WHITTLESEY AVE.
SECTION 2: ALTERNATE 1040
38 WHITTLESEY AVE., P.O. BOX 440
P.O. BOX 440
SECTION 3: SIGNATURES
NORWALK, OHIO 44857-0440
NORWALK OHIO 44857-0440
ALL RESIDENTS OF THE CITY OF NORWALK MUST FILE A
ENTER NAME AND ADDRESS BELOW
TAX RETURN BY APRIL 15,
2013
IF REQUIRED TO FILE
FEDERAL 1040, COPY MUST BE
ATTACHED OR NORWALK ALTERNATE 1040 FORM MUST BE
COMPLETED, SIGNED & ATTACHED
FOR QUESTIONS OR ASSISTANCE IN PREPARING YOUR
RETURN, CALL (419) 663-6720 OR VISIT THE INCOME TAX
DEPARTMENT AT 38 WHITTLESEY AVENUE, NORWALK, OHIO
(NEXT TO THE FIRE STATION). NORWALK TAX FORMS MAY BE
DOWNLOADED FROM OUR WEBSITE:
Soc. Sec. #
e-mail:
Spouse Soc. Sec. #
SECTION 1 - EXEMPTION CERTIFICATE
LATE FILING PENALTY
(If a joint return, spouse’s first name, initial and Soc. Sec. #)
MY SOLE INCOME FOR
WAS ONE OF THE FOLLOWING THEREFORE; THIS EXEMPTION CERTIFICATE SATISFIES THE
FILING REQUIREMENT. PLEASE
2012
2012
CHECK THE APPROPRIATE BOX IN THIS SECTION 1, SIGN BELOW IN SECTION 3, DATE AND MAIL THIS FORM; A SIGNATURE IS REQUIRED.
SOCIAL SECURITY BENEFITS, PENSION
WORKERS COMPENSATION
ACTIVE MILITARY SERVICE
(Must include W-2)
INTEREST AND/OR DIVIDEND INCOME
TOTAL PERMANENT DISABILITY
A.D.C./GENERAL PUBLIC ASSISTANCE
UNEMPLOYMENT COMPENSATION
UNDER AGE 18 FOR ENTIRE TAX YEAR (If applying for a refund, copy of driver’s license or birth certificate required)
OTHER (PLEASE EXPLAIN)
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(Partial Year Residents In
Are Required To File)
2011
2012
SECTION 2 - ALTERNATE 1040
****THIS SECTION MUST BE COMPLETED ONLY IF YOU CHOOSE NOT TO SUBMIT A PHOTO
COPY OF YOUR FEDERAL 1040, 1040A OR 1040EZ. IT IS FILED ALONG WITH YOUR CITY OF NORWALK FINAL INCOME TAX RETURN AND ANY COPIES
OF FEDERAL SCHEDULES C, C-EZ, E, F, IF APPLICABLE. SCHEDULES A AND 2106 ARE NECESSARY IF TAXPAYER SEEKS EMPLOYEE BUSINESS
EXPENSE DEDUCTION.**** SIGNATURE REQUIRED, SEE SECTION 3
FILING STATUS:
Single
Married filing joint return (even if only one had income)
Married filing separate return
Enter spouse’s social security number above and full name here:
Head of household (with qualifying person). If the qualifying person is a child but not your dependent, enter
the child’s name here:
Qualifying widow(er) with dependent child. Year spouse died:
ENTER THE EXACT FIGURES USED ON YOUR FEDERAL FORM 1040, 1040A, 1040EZ AND 1040TEL.
1040
1040A
1040EZ
1040TEL
Line
7
7
1
Wages, salaries, tips, etc. (attach Form(s) W-2)
If using 1040TEL, DO NOT INCLUDE INTEREST
Line
12
N/A
N/A
N/A
Business income or (loss) (attach Schedule C or C-EZ,
including cost of goods manufactured and/or sold)
Line
17
N/A
N/A
N/A
Rental real estate, royalties, partnerships,
S Corporations, trusts, etc. (attach Schedule E)
Line
18
N/A
N/A
N/A
Farm income or (loss) (attach Schedule F)
Line
21
N/A
N/A
N/A
Other income (list type and amount and attach documentation)
SECTION 3 - SIGNATURES
CHECK BOX NEXT TO SIGNATURE TO AUTHORIZE CITY TO DISCUSS RETURN WITH PREPARER.
THE UNDERSIGNED DECLARES THAT THIS FORM (AS COMPLETED IN LIEU OF FORM 1040, 1040A, 1040EZ OR 1040TEL), IS A TRUE, CORRECT AND
COMPLETE FORM FOR THE TAXABLE PERIOD STATED AND THAT THE FIGURES USED HEREIN ARE THE SAME AS USED FOR FEDERAL INCOME TAX
PURPOSES. I certify that all information in Section 1 (Exemption) to be true & correct.
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Address or Name and Address of Firm or Employer - Phone No. (
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