Ex Generic Form - Non Taxable Income - Newark City Income Tax Office - Ohio Page 3

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EX Generic
Enter year that you are filing
Step 1
Please answer the following questions about this past year:
Yes
No
Were you employed?
Did you have gambling/lottery winnings?
Were you self-employed?
Did you receive rental income?
If you answered yes to any of the above questions, this is not the correct return. See the
instructions to determine which return is right for you.
Step 2
Name
Account
Address
SSN
XXX-XX-
SSN
XXX-XX-
Phone
Email
Filing Status
Single
Married filing separately
Married filing joint
Head of household
Step 3
My income is exempt from Newark Tax because:
Please check boxes below
You
Spouse
Under 18 - enter birth date
Retired - received pension income -enter date retired
Did not live in Newark - enter date moved out
Student - enter anticipated date of graduation
Active duty military for the entire year
I had no taxable income for the year
Other
If you are filing for a tax year prior to 2010, your return is subject to penalty for failure to
file by the orginal due date. Enter the amount of penalty due to the right (see
instructions). This payment is due with your return. Thank you.
I hereby declare that the above information is true, correct, and complete
Signature
Date
Signature
Date
All forms received by the Newark Tax Office are subject to review.
Mail to:
Questions?
740-670-7580 phone
Newark City Tax Office
740-670-7581 fax
PO Box 4577
citytax@newarkohio.net
Newark, OH 43058-4577

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