Income Tax Return Form - City Of Ontario - 2010 Page 3
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32010
----- INDIVIDUAL DECLARATION OF FILING EXEMPTION OF ONTARIO, OHIO CITY INCOME TAX RETURN -----
ONTARIO CITY ORDINANCE
Mandatory tax filing became effective January 1, 2003. All residents eighteen years of age and older shall file an Annual Return,
notwithstanding whether Ontario Municipal Income Tax has been withheld by an employer or for any other reason, except in such cases
when a Resident Qualifies for an Exemption.
If you qualify under one of the below listed categories, the filing of this declaration will satisfy your obligation as imposed by The
Ontario City Income Tax Mandatory Filing Ordinance requiring the filing of an Income Tax Return.
If any of the categories shown below apply to any persons in your household, check the appropriate category, have all exempt
individuals sign and file this form by April 15th. Return this completed form by April 15th to: Ontario Municipal Income Tax
P.O. Box 166
Ontario, Ohio 44862
NOTE: ONLY EXEMPT INDIVIDUALS SHOULD COMPLETE AND SIGN THIS EXEMPTION FORM.
(OTHERWISE YOU MUST FILE AN ANNUAL MUNICIPAL INCOME TAX RETURN)
I AM QUALIFIED TO FILE AN ONTARIO INCOME TAX EXEMPTION RETURN BECAUSE:
1. ________ Retired. No income subject to the Ontario City Income Tax for entire tax year of 2010. – I received only Social
Security, Pension, Interest or Dividend Income. I do not own rental property. I am not self-employed.
Date retired:___________________________ Employer’s Name: _________________________________
1._______
2. ________ Unemployed. No earned income for the entire tax year of 2010.
3. _______ Homemaker
4. _______ Disabled
5. _______ Welfare
6. _______ ADC
1._______
7. ________ Had gross earnings of $300.00 or less for the entire tax year of 2010 (must attach documentation).
8. ________ A member of the Armed Forces of the United States for the entire year of 2010.
(This does not include civilians employed by the Military or National Guard.)
9. ________ Non-Resident. I never lived in Ontario, Ohio and I do not work in or receive income from Ontario, Ohio.
10. ________ I moved from Ontario, Ohio before this tax year and have no income subject to Ontario, Ohio City Income
Tax.
3._______
I UNDERSTAND THAT I MUST FILE A CITY OF ONTARIO, OHIO TAX RETURN IF ANY OF THESE EXEMPT CONDITIONS CHANGE IN
FUTURE YEARS.
I DECLARE THE INFORMATION SUPPLIED TO BE TRUE, CORRECT AND COMPLETE. ANY MISREPRESENTATION WILL BE IN VIOLATION OF
THE CODIFIED ORDINANCES OF THE CITY OF ONTARIO, OHIO AND SUBJECT TO PENALTIES THEREIN IMPOSED.
Name
Exemption Category Number(s)
Please list exemption number(s) checked.
Address
Social Security Number
Exempt Person’s
Date
Age
Phone
Signature
Name
Exemption Category Number(s)
Please list exemption number(s) checked.
Address
Social Security Number
Exempt Person’s
Date
Age
Phone
Signature
Name
Exemption Category Number(s)
Please list exemption number(s) checked.
Address
Social Security Number
Exempt Person’s
Date
Age
Phone
Signature
PLEASE NOTE: Signature, Address and Social Security Number must be completed by each exempt individual.
Page 3
Phone: (419) 529-3045 • Fax: (419) 529-6132 • Web Site:
INCOME TAX OFFICE COPY
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