Form 37b - Individual Income Tax Return - 2010 Page 2
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Form 37B (2010)
Page
Name of taxpayer(s) shown on page 1
Your social security number
Spouse’s SSN if filing joint exemption
Year
Declaration of Exemption
I am not reporting municipal (city or village) taxable income because:
1.
I had no municipal taxable income for the year indicated above. Attach a copy of page 1 of your federal Form 1040, 1040A
or 1040EZ. If you did not file a federal return because you did not meet the federal minimum gross income requirements,
check here:
.
2.
I was a member of the armed forces of the United States and had no income for the year indicated above other than
military pay, military allowances, interest income, and/or dividend income.
3.
I was under 18 years of age for the entire year (or the appropriate age for my resident
Mo
Day
Year
municipality as indicated below in the Special Notes). Attach a copy of your birth
Date of Birth
certificate or driver’s license.
4.
I am a retired individual and received only pension, social security, interest and/or
Mo
Day
Year
Retirement Date
dividend income for the year indicated above. Attach a copy of page 1 of your federal
Form 1040, 1040A or 1040EZ. If you did not file a federal return, attach a copy of your
1099-R or statement of Social Security Earnings.
5.
Prior to the first day of the year indicated above, I moved out of a RITA municipality, and I had no
Mo
Day
Year
Date of Move
rental or self-employment income earned in a RITA municipality during the year indicated above.
Current Home Address (number and street)
City
State
Zip
Prior Home Address (number and street)
City
State
Zip
6.
The taxpayer indicated above is deceased. Indicate the date of death to the right.
Mo
Day
Year
Date of Death
7.
I am not exempt from tax. However, I filed and reported my taxable income to RITA on
a joint return filed with my spouse.
Spouse’s name
Spouse’s social security number
8.
I meet the requirements of the Military Spouse Residency Relief Act for the year indicated above. Attach copies of Form
DD 2058, your valid military spouse ID card, and your spouse’s most recent LES.
Address of legal domicile (number and street)
City
State
Zip
Taxpayer’s Signature
Under penalties of perjury, I declare that I have examined this declaration of exemption, and to the best of my knowledge and belief, it is true, correct
and complete.
Your signature
Date
Spouse’s signature if joint exemption
Date
Special Notes
The under 18 years of age exemption does not apply to
The following municipalities have additional special rules:
residents of the following municipalities:
Lockland
•
•
Addyston
Ripley
•
Any Lockland taxpayer who is 65 yrs. of age or older on
•
•
Campbell
Riverside
December 21 of the taxable year and has gross taxable
•
•
Fremont
Rossford
income of $1200.00 or less is exempt. An exemption certificate
•
•
Girard
Saint Paris
must be filed.
•
•
Lockland
Tontogany
Ottawa
•
•
•
Middleport
Wintersville
Students 18 years of age or under and earning less than
•
•
Oxford
Youngstown
$600.00/yr are exempt from paying municipal income tax.
Reynoldsburg & Worthington
The following municipalities use an under 16 years of age
•
exemption instead of an under 18 years of age exemption:
Income of the mentally retarded or developmentally disabled
•
•
while working in a government funded workshop for less
Avon Lake
Jewett
than minimum wage is exempt.
•
•
Fairborn
Yellow Springs
•
Jackson Center
Sherwood
•
The first $10,000.00 of any salaries, wages, commissions
For the under 18 years of age exemption to apply, the
and other compensation earned by any natural person
resident must be a full-time elementary, junior high or high
sixty-five (65) years of age and over is exempt.
school student if a resident of:
•
Cardington
Yellow Springs
•
Individuals under 18 years of age who are newspaper
carriers are exempt from paying municipal income tax.
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