Application For Exemption - City Of Mount Vernon printable pdf download

Application For Exemption - City Of Mount Vernon

200___APPLICATION FOR EXEMPTION

CITY OF MOUNT VERNON

DIVISION OF INCOME TAX

40 PUBLIC SQUARE

MOUNT VERNON OH 43050

740-393-9524

FAX 740-397-5293

If you are not subject to Mount Vernon City Income Tax, please complete this Application for Exemption and return

it to the Income Tax Office within 3 ½ months after year end.

NAME

STREET

CITY, STATE, ZIP COE

SOCIAL SECURITY NO. __________________-____________-_______________

___ RETIRED, ONLY INCOME IS FROM NON-TAXABLE SOURCE. LIST SOURCE ______________________________________

_________________________________________

___ NO INCOME FOR ALL OF TAX YEAR MEANS OF SUPPORT _____________________________________________________

___ UNDER 18 YEARS OF AGE FOR ENTIRE YEAR.

DATE OF BIRTH ___________________

___ ACTIVE DUTY MILITARY FOR ENTIRE YEAR, EXCEPT CIVILIAN EMPLOYED BY MILITARY.

___ NON-RESIDENT FOR ENTIRE YEAR.

DATE OF MOVE _____________________

You must qualify under one of the above exemptions to be exempt from The City Income Tax.

DECLARATION: I declare this information as true and complete.

Current source(s) of income ______________________________________________________________

_________________________________________________________________________________________________________

Your signature

Date

Application For Exemption - City Of Mount Vernon