Exemption Certificate Form - Division Of Taxation - 2016

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EXEMPTION CERTIFICATE
I LIVE IN A MANDATORY FILING CITY AND I AM NOT REQUIRED TO PAY CITY INCOME TAX BECAUSE:
@
@
RETIRED, received only pension, Social Security, interest or
NO EARNED INCOME FOR THE ENTIRE YEAR
1.
4.
dividend income
2016. (Public Assistance, Unemployment, SSI, etc.)
@
@
AN ACTIVE MEMBER OF THE ARMED FORCES OF THE
BUSINESS CLOSED OR RENTAL PROPERTY
2.
5.
UNITED STATES FOR THE ENTIRE YEAR 2016. (This does not
SOLD _____ / _____ / _____ (date)
include civilians employed by the military or National Guard.)
@
UNDER 18 FOR THE ENTIRE YEAR 2016.
3.
*see reverse for exceptions
IF EXEMPT, COMPLETE, DETACH AND RETURN THE EXEMPTION CERTIFICATE IN THE ENCLOSED ENVELOPE.
KEEP TOP PORTION FOR YOUR RECORDS.
IF YOU ARE NOT FILING THIS EXEMPTION CERTIFICATE, PLEASE DISCARD.
2016 EXEMPTION CERTIFICATE
CCA – DIVISION OF TAXATION
@
PO BOX 94810
CLEVELAND OH 44101-4810
SHOW NAME OR ADDRESS CHANGES ON REVERSE.
Name
Social Security No.
–
–
Name of spouse if joint return
– –
Current address
Apt. #
City
State
Zip
@ @
@
I LIVE IN A MANDATORY FILING CITY AND I AM NOT REQUIRED TO PAY CITY INCOME TAX BECAUSE:
1.
4.
RETIRED, received only pension, Social Security, Interest or Dividend Income
NO EARNED INCOME FOR THE ENTIRE YEAR 2016.
@
2.
AN ACTIVE MEMBER OF THE ARMED FORCES OF THE UNITED
(Public Assistance, Unemployment, SSI, etc.)
STATES FOR THE ENTIRE YEAR 2016. (This does not include
@
5.
BUSINESS CLOSED OR RENTAL PROPERTY SOLD ___ / ___ / ___ (date)
@
civilians employed by the military or National Guard.)
@
3.
UNDER 18 FOR THE ENTIRE YEAR 2016.
Do you authorize your preparer to contact us regarding this return? YES
NO
*see reverse for exceptions
PHONE NUMBER
SIGNATURE OF TAXPAYER
SIGNATURE OF SPOUSE,
SIGNATURE OF PREPARER,
DATE
IF JOINT RETURN
IF NOT TAXPAYER

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