NAME and ADDRESS (Please print or type)                                                 EXEMPTION CERTIFICATE
                                                        Tax Year                        INCOME TAX DIVISION
                                                                                        1 CASCADE PLAZA- SUITE 100
                                                                                        AKRON, OH 44308 -1161 
                                                        If you believe that you are not subject to the City Income Tax please
                                                                                        complete this form and return it to our office.
                                                        SUBSEQUENT RECEIPT OF TAXABLE INCOME VOIDS THIS EXEMPTION CERTIFICATE

    ACCOUNT NUMBER       YOUR SOCIAL SECURITY NUMBER    SPOUSE'S SOCIAL SECURITY NUMBER DAYTIME PHONE NUMBER

          I believe that I am not required to file a city income tax return for the year shown above because:
MOVED FROM CITY                                         DATE OF MOVE
UNDER 18 FOR ENTIRE YEAR                                DATE OF BIRTH
TOTAL DISABILITY                                        DATE DISABLED
RETIRED INDIVIDUAL RECEIVING ONLY PENSION, SOCIAL SECURITY, INTEREST, OR DIVIDEND INCOME
DATE RETIRED
THE COMPANY OR ORGANIZATION FROM WHICH YOU RETIRED:
SURVIVING SPOUSE RECEIVING ONLY PENSION, SOCIAL SECURITY, INTEREST, OR DIVIDEND INCOME
NO TAXABLE INCOME FOR THE ENTIRE YEAR. REASON:
MEMBER OF U S. ARMED FORCES FOR ENTIRE YEAR (THIS DOES NOT INCLUDE CIVILIANS EMPLOYED BY THE MILITARY OR NATIONAL GUARD)
I DECLARE THE INFORMATION SUPPLIED ABOVE TO BE TRUE, CORRECT, AND COMPLETE.
SIGN HERE                                          DATE SPOUSE SIGNATURE
                                                                                                                                       Rev 2/21
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