Fillable Form 37b - Rita Individual Income Tax Return

Form 37b - Rita Individual Income Tax Return - 2014 Page 2

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Form 37B (2014)

Page

Name of taxpayer(s) shown on page 1

Your social security number

Spouse’s SSN if filing joint exemption Year

Declaration of Exemption

I am not reporting municipal (city or village) taxable income because:

I had no municipal taxable income for the year indicated above. Attach a copy of page 1 of your federal Form 1040, 1040A

or 1040EZ. If you did not file a federal return because you did not meet the federal minimum gross income requirements,

check here:

I was a member of the armed forces of the United States and had no income for the year indicated above other than

military pay, military allowances, interest income, and/or dividend income.

I was under 18 years of age for the entire year (or the appropriate age for my resident

Day

Year

municipality as indicated on page 1 or see the RITA Member list at for

Date of Birth

detailed municipality information regarding the appropriate age for your resident municipality).

I am a retired individual and received only pension, social security, interest and/or

dividend income for the year indicated above. Attach a copy of page 1 of your federal

Form 1040, 1040A or 1040EZ. If you did not file a federal return, attach a copy of your

Day

Year

Retirement Date

1099-R or statement of Social Security Earnings.

Day

Year

Prior to the first day of the year indicated above, I moved out of a RITA municipality, and I had

Date of Move

no rental or self-employment income earned in a RITA municipality during the year indicated above.

Current Home Address (number and street)

City

State

Zip

Prior Home Address (number and street)

City

State

Zip

Day

Year

Date of Death

The taxpayer indicated above is deceased. Indicate the date of death to the right.

I am not exempt from tax. However, I filed and reported my taxable income to RITA on

a joint return filed with my spouse.

Spouse’s name

Spouse’s social security number

I meet the requirements of the Military Spouse Residency Relief Act for the year indicated above. Attach copies of Form

DD 2058, your valid military spouse ID card, and your spouse’s most recent LES.

Address of legal domicile (number and street)

City

State

Zip

Taxpayer’s Signature

Under penalties of perjury, I declare that I have examined this Declaration of Exemption, and to the best of my knowledge and belief, it is true, correct

and complete.

Your signature

Spouse’s signature if joint exemption

Date

Special Individual Notes

Each municipality has specific instructions or requirements for filing returns, reporting income and/or making estimated payments.

Go to for detailed information; click on the Municipalities link (top banner) and then click on RITA Member List link.

Next, select the applicable municipality and click on the Individual Notes.