Exemption Certificate Form - 2009
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1EXEMPTION 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.
RETIRED, received only pension, Social Security, interest or dividend income
4.
NO EARNED INCOME FOR THE ENTIRE YEAR 2009.
@
2.
AN ACTIVE MEMBER OF THE ARMED FORCES OF THE UNITED
(Public Assistance, Unemployment, SSI, etc.)
@
5.
STATES FOR THE ENTIRE YEAR 2009. (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 2009.
*see reverse for exceptions
KEEP TOP PORTION FOR YOUR RECORDS
If you have qualified and completed the Exemption Certificate,
detach
here and return in the envelope provided.
CCA MUNICIPAL INCOME TAX
2009 EXEMPTION CERTIFICATE
205 W SAINT CLAIR AVE
@
CLEVELAND OH 44113-1503
SHOW NAME OR ADDRESS CHANGES ON REVERSE.
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 2009.
@
2.
AN ACTIVE MEMBER OF THE ARMED FORCES OF THE UNITED
(Public Assistance, Unemployment, SSI, etc.)
@
STATES FOR THE ENTIRE YEAR 2009. (This does not include
5.
BUSINESS CLOSED OR RENTAL PROPERTY SOLD ___ / ___ / ___ (date)
civilians employed by the military or National Guard.)
@
3.
UNDER 18 FOR THE ENTIRE YEAR 2009.
@
@
Do you authorize your preparer to contact us regarding this return? YES
NO
*see reverse for exceptions
PHONE NUMBER
SIGNATURE OF PREPARER,
SIGNATURE OF TAXPAYER
SIGNATURE OF SPOUSE,
DATE
IF JOINT RETURN
IF NOT TAXPAYER
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