City Of Green Exemption Certificate For Retired Individuals - 2011

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City of Green
Phone: 330-896-6622
Income Tax Division
Fax: 330-896-6927
Email:
Website:
Re: Exemption Certificate for Retired Individuals
TAX YEAR 2011
Due Date: April 17, 2012
Account #: ___________
As a convenience to retirees, the City of Green Income Tax Division has initiated a program which will
allow retirees who receive only non-taxable income such as: social security, pensions, dividends or
interest to file an “Exemption Certificate.”
In order to qualify for this exemption, please complete the form below and return it in the envelope
provided. If you or your spouse have any kind of taxable income, you are not eligible for this
exemption.
If you sign the Exemption Certificate for Retired Individuals, and in the future, you or your spouse
receive taxable income, the Exemption Certificate will not be valid and you will be required to file a
City Tax Return.
For example: If you begin working, start a business, own rental property or receive lottery
winnings, you will be required to file a City of Green Tax Return.
If in the future you are required to file a City Tax Return, you must notify this office.
If you do not return this form, it will be your responsibility to file a City Tax Return each year.
C
G
ITY OF
REEN
Exemption Certificate for Retired Individuals
Tax Year 2011
I am completing this Exemption Certificate because I/we are retired individual(s) receiving only
non-taxable income.
I DECLARE THIS STATEMENT TO BE TRUE, CORRECT AND COMPLETE, AND WILL
IMMEDIATELY NOTIFY THE DIVISION OF TAXATION IF THE EXEMPTION BECOMES INVALID.
Signature______________________________ Date________________ Spouse’s Signature ________________________________
Please print the following information:
Name(s) ______________________________________________
_____________________________________________
Social Security # _______________________________________
_____________________________________________
Address: ____________________________________________
Phone Number_________________________________
City, State, Zip_______________________________________________________________________________________________
Acct #_____________________

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