Exemption Form Sidney
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1
2Mail completed form to:
City of Sidney
City of Sidney, Ohio
Revenue Collections – Tax
Declaration of Exemption
201 W. Poplar St.
Sidney OH 45365
(See Instructions Below on Page 2)
This exemption form may NOT be used by those engaged in business, including those receiving self‐employment or rental
income within the City of Sidney.
Effective with the 2009 tax year, the City of Sidney requires mandatory filing of City tax returns. If you meet one of the
following exemptions, the filing of this declaration will serve to meet the filing requirement.
_______________________________________________
_______________________________________________
SOCIAL SECURITY NUMBER
LAST NAME FIRST NAME INITIAL
_______________________________________________
_______________________________________________
PRESENT ADDRESS
APT #
CITY
STATE
ZIP
Month ‐‐ Day ‐‐‐ Year
1.
I am a PERMANENTLY RETIRED person receiving only pension
income or other non‐taxable income for the year…………...........DATE RETIRED:
(Continued exemption unless you become employed or earn Sidney taxable income
during any subsequent year.)
Month ‐‐ Day ‐‐‐ Year
I am a PERMANENTLY DISABLED person receiving only non‐taxable
2.
income for the year……………….…………….………………DATE DISABLED:
(Attach copy of proof of permanent disability.) (Continued exemption unless you become
employed or earn Sidney taxable income during any subsequent year.)
3.
I had no SIDNEY TAXABLE INCOME for the entire year of __________________
(Attach a copy of Page 1 of your Federal 1040 Form) (Current Year Exempt Only)
4.
I did not reside in the City of Sidney for any part of the tax year _________.
Provide Move In or Move Out date and check In or Out check box below.
Month ‐‐ Day ‐‐‐ Year
DATE OF MOVE:
IN or
OUT of Sidney:
Month ‐‐ Day ‐‐‐ Year
5.
Taxpayer is DECEASED…………..………….…………………DATE OF DEATH:
6.
I was on active duty as a member of the ARMED FORCES, including National Guard, of the
United States for the entire year of ____________ and received no income taxable by the
City of Sidney. (This does not include civilians employed by the military.)
(Current Year Exempt Only) (Attach copy of proof of your military status.)
7.
I am FILING a JOINT return with my spouse. (Spouse’s name and social security number
must be completed below.)
_______________________________________________ ____________________________
SPOUSE’S NAME (LAST, FIRST & INITIAL)
SPOUSE’S SOCIAL SECURITY NUMBER
I hereby declare the information supplied above to be true, correct and complete.
(Please print form and sign below)
Signature_______________________________________________ Date ________________
Spouse’s Signature_______________________________________ Date ________________
Phone Number _______________________________________________
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