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Regional Income Tax Agency
Individual Declaration of Exemption

NOTE:                                                                             Mail Declaration to: 
Do not use this form for refund requests.                                         REGIONAL INCOME TAX AGENCY 
If you need to request a refund, please separately submit a completed             P.O. BOX 94801                                                        Tax Year  ________
Form 10A (available at ritaohio.com). Please do not attach a refund request       Cleveland, Ohio 44101-4801
to this Declaration of Exemption. 
SOCIAL SECURITY NUMBER                                               SPOUSE'S SOCIAL SECURITY NUMBER

FIRST NAME                                                              M.I.      LAST NAME

SPOUSE'S FIRST NAME                                                     M.I.      SPOUSE'S LAST NAME (IF DIFFERENT)

CURRENT STREET NUMBER                   STREET NAME

CITY NAME                                                                                                                          STATE        ZIP CODE

PHONE NUMBER

I believe that I am not required to file a municipal income tax return for the year shown above because:
(Please CIRCLE the number of the statement that best applies to you)
1.  NO TAXABLE INCOME* for the entire year.  If Joint account, CIRCLE this statement only if both you and your spouse have NO TAXABLE INCOME*. Enclose page  1  s -2 and Schedule 1 of your
   Federal Form 1040.       Ifyou have taxable income* and generally do not meet other exemptions below, your income is not exempt and you must file a RITA Form 37 (login to MyAccount at ritaohio.com).
    *TAXABLE INCOME for municipal income tax purposes includes W-2 income, Federal Schedule C, E, F, 1099-MISC or Form 4797 income.
2.  I was a member of the U.S. ARMED FORCES (including the NATIONAL GUARD) and had no other taxable income* for all of the tax year.
    (Not including civilians employed by the military)
3.  I was UNDER AGE 18 for the entire year.  (Enclose a copy of your Birth Certificate or Driver's License).  Date of Birth:                                       ______________
                                                                                                                                                                   M  M / DD / YY
4.  I am a RETIRED individual receiving only pension, social security, interest, or dividend income.                                        Date Retired:    
                                                                                                                                                                   ______________
                                                                                                                                                                     M  M / DD / YY
    SPOUSE is a RETIRED individual receiving only pension, social security, interest, or dividend income.
    (Enclose page s1-2 and Schedule 1      of the Federal Form 1040)                                                        Spouse's   Date Retired: ______________
                                                                                                                                                                     M  M / DD / YY
5.  Prior to January 1, I MOVED from a RITA municipality.  (Enclose proof of new address) 
                                                                                                                                                      Date of 
    Previous Address  _______________________________________________________________________________                                                Move In:   ______________
                                                                                                                                                                       
                              Street # and name                                             City                            State    Zip                           M  M / DD / YY
6. Taxpayer is DECEASED.  (Enclose copy of Death Certificate)                                                                          Date of Death:    
                                                                                                                                                                   ______________
                                                                                                                                                                     M  M / DD / YY
   SPOUSE is DECEASED.  (Enclose copy of Death Certificate)                                                                 Spouse's Date of Death:    
                                                                                                                                                                   ______________
                                                                                                                                                                     M  M / DD / YY
7. I am filing a RITA return JOINTLY with my Spouse and their name and social security number are indicated in the address section at the top of the form.
                              Refunds can be requested by submitting a form 10A found at ritaohio.com
THE BELOW SIGNED DECLARES THAT THIS EXEMPTION IS TRUE, CORRECT, AND COMPLETE                                                                            .

_________________________________________________________________________________ 
Taxpayer's Signature                                                                                                                            DATE 

_________________________________________________________________________________
Spouse's Signature                                                                                                                               DATE