Individual Declaration Of Exemption - Warren City Income Tax Division Form printable pdf download

City of Warren, Ohio

Income Tax Division

258 E Market St

Individual

Warren, OH 44481

John D. Homlitas, Treasurer

Declaration of Exemption

Thomas J. Gaffney, CPA, Tax

This Exemption form may not be used by

Administrator

Tax Year: _______

those engaged in business, including

Telephone: 330.841.2551

those receiving self-employment,

FAX: 330.841.2626

Federal K-1 distributions or rental

property located in The City of Warren

The City of Warren currently required mandatory filing of City tax returns. If you meet one of the following

exemptions, the filing of this Declaration of Exemption will serve to meet the filing requirement.

___________________________

_______________________________

Social Security Number

Spouse’s Social Security Number

_________________________________________

Last Name

First Name

Initial

Spouse’s Last Name

First Name

Initial

___________________________________

_______________

_______

________

Present Address

Apt #

City

State

Zip Code

Please circle one of the following and attach documentation when necessary

Account# ____________

I am permanently retired as of _______/______/_______ (attach a copy of Federal Form 1040 page 1)

2. No Taxable income for all of the tax year _______________. (circle one below)

Unemployment

Welfare

ADC

Other:_______________

3. I was under 16 years of age for the entire year of _________. Date of Birth:_______/______/_______

(Please attach documentation: copy of Birth Certificate or Driver’s License)

4. Active Military Duty for the entire year of _________________. (Excludes civilian employment)

5. I did not reside in the City of Warren for any part of the year. Date moved out of Warren:____/____/____

(Please attach proof of move such as lease or proof of purchase date).

6. I am filing jointly with my spouse, ______________________ Social Security #____________________

7. Taxpayer is deceased. Date of Death: _____/_____/_____. (Please attach copy of death certificate).

I hereby declare the information supplied above to be true, correct, and complete

Signature_____________________________________________

Date ___________________

Spouse’s Signature _____________________________________

Date ___________________

Telephone Number ______________________

Mail completed form to:

Warren City Income Tax

PO Box 230

Warren, OH 44482

Form may be faxed: 330.841.2626

(Instructions on reverse side)

Individual Declaration Of Exemption - Warren City Income Tax Division Form

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