Individual Declaration Of Exemption - 2011
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12011
CLEVELAND
REGIONAL INCOME TAX AGENCY
800-860-7482
COLUMBUS
866-721-7482
YOUNGSTOWN
P.O. BOX 94801
866-750-7482
TDD
440-526-5332
Cleveland, Ohio 44101-4801
INDIVIDUAL DECLARATION OF EXEMPTION
SOCIAL SECURITY NUMBER
SPOUSE'S SOCIAL SECURITY NUMBER
FIRST NAME
M.I.
LAST NAME
SPOUSE'S FIRST NAME
M.I.
SPOUSE'S LAST NAME (IF DIFFERENT)
ADDRESS NUMBER
STREET NAME
CITY NAME
STATE
ZIP CODE
DAY PHONE
EVENING PHONE
I AM NOT REPORTING TAXABLE INCOME FOR 2011 BECAUSE:
1.
I had NO TAXABLE INCOME for the entire year of 2011 (Attach a copy of your Federal 1040 Form)
2.
I was a member of the ARMED FORCES, including the National Guard, of the United States for all of 2011
and had no other taxable income. (This does not include civilians employed by the military)
3.
I was UNDER AGE 18 for all of 2011……………………………………………………………………..... Date of Birth:
____/____/____
)
MO DAY YR
(Attach copy of Birth Certificate or Driver’s License. For exceptions, see special notes
4.
I am a RETIRED individual receiving only pension, social security, interest,
dividends or other non-taxable income for all of 2011 …………………………………………………….Date Retired:
____/____/____
)
MO DAY YR
(Attach a copy of page 1 of your 2011 Federal 1040 return
5.
Prior to January 1, 2011, I moved from a RITA municipality………………………………………………Date of Move:
____/____/____
(indicate previous address below)
MO DAY YR
__________________________________________________________________________________________
PREVIOUS ADDRESS
6.
Taxpayer is Deceased…………………………………………………………………………………………Date of Death:
____/____/____
MO DAY YR
(Please enclose copy of Death Certificate)
7.
I am filing a 2011 RITA return Jointly, with my Spouse. ______________________________________________
______-_____-_________
Spouse’s Name
Spouse’s SSN
________________________________________ ________________________________________
SIGNATURE
DATE
SPOUSE’S SIGNATURE
DATE
THE ABOVE SIGNED DECLARES THAT THIS RETURN IS TRUE, CORRECT AND COMPLETE FOR THE TAX YEAR 2011.
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