Individual Declaration Of Exemption Form - Broadview Heights, Ohio - 2009
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12009
REGIONAL INCOME TAX AGENCY
YOUNGSTOWN LOCAL
(866) 750-7482
CLEVELAND LOCAL
(440) 526-0900
P.O. BOX 477900
COLUMBUS LOCAL
(866) 721-7482
TDD
(440) 526-5332
Broadview Heights, Ohio 44147
TOLL FREE
1-800-860-7482
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 2009 BECAUSE:
1.
I had NO TAXABLE INCOME for the entire year of 2009 (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 2009
and had no other taxable income. (This does not include civilians employed by the military)
3.
I was UNDER AGE 18 for all of 2009……………………………………………………………………..... 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 2009 …………………………………………………….Date Retired:
____/____/____
)
MO DAY YR
(Attach a copy of page 1 of your 2009 Federal 1040 return
5.
Prior to January 1, 2009, I moved from a RITA municipality………………………………………………Date of Move:
____/____/____
(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 2009 RITA return Jointly, with my Spouse. ______________________________________________
______-_____-_________
Spouse’s Name
Spouse’s SSN
________________________________________ ________________________________________
SIGNATURE
DATE
SPOUSE’S SIGNATURE
DATE
THE ABOVE SIGNED DELARES THAT THIS RETURN IS TRUE, CORRECT AND COMPLETE FOR THE TAX YEAR 2009.
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