City of Warren, Ohio 
 Income Tax Division 
 258 E Market St 
                                                                   Individual 
 Warren, OH 44481                                                                                                
 Tom Letson, Treasurer 
                                                                Declaration of Exemption                 
                                   Thomas J. Gaffney, CPA, Tax                                      This Exemption form may not be used by 
                    Administrator                                 Tax Year: _______                 those engaged in business, including 
 Telephone:  330.841.2551 
 FAX:  330.841.2626                                                                                 those receiving self-employment, 
 www.warren.org                                                                                     Federal K-1 distributions or rental 
                                                                 
                                                                                                    property located in The City of Warren 
 
The City of Warren currently required mandatory filing of City tax returns.  If you meet one of the following 
exemptions, the filing of this Declaration of Exemption will serve to meet the filing requirement.       
 
___________________________                                               _______________________________ 
Social Security Number                                                          Spouse’s Social Security Number 
 
_________________________________________                                 _________________________________________         
Last Name                     First Name               Initial                       Spouse’s Last Name          First Name            Initial            
 
___________________________________                                       _______________               _______         ________      
Present Address                                  Apt #                                    City                                    State                       Zip Code        
 
Please circle one of the following and attach documentation when necessary               Account# ____________ 
 
  1.  I am permanently retired as of _______/______/_______  (attach a copy of Federal Form 1040 page 1) 
  2. No Taxable income for all of the tax year _______________.  (circle one below) 
                 Unemployment        Welfare         ADC         Other:_______________ 
  3. I was under 16 years of age for the entire year of _________.  Date of Birth:_______/______/_______ 
          (Please attach documentation: copy of Birth Certificate or Driver’s License) 
  4. Active Military Duty for the entire year of _________________.  (Excludes civilian employment) 
  5. I did not reside in the City of Warren for any part of the year.  Date moved out of Warren:____/____/____ 
       (Please attach proof of move such as lease or proof of purchase date).   
  6. I am filing jointly with my spouse, ______________________  Social Security #____________________ 
  7. Taxpayer is deceased.  Date of Death: _____/_____/_____. (Please attach copy of death certificate). 
        
I hereby declare the information supplied above to be true, correct, and complete 
 
Signature_____________________________________________               Date ___________________ 
 
Spouse’s Signature _____________________________________               Date ___________________ 
 
Telephone Number ______________________ 
 
                                                                  Mail completed form to: 
                                                                  Warren City Income Tax 
                                                                   PO Box 230 
                                                                   Warren, OH 44482 
                                                                  Form may be faxed:  330.841.2626 
        
                                                                   (Instructions on reverse side) 
        

                                                                       INSTRUCTIONS FOR FORM DECLARATION OF EXEMPTION 

                                                 If you were a wage earner, were self-employed, owned rental property, had lottery or gambling winnings, or 
                                                 received a distribution from a partnership or s-corporation, you are not exempt from the mandatory filing 
                                                 requirement and may NOT use this form. 

                                                 1. If you were retired for the entire year in question, receiving only pension income, social security income, 
                                                               and dividends or interest income and do not anticipate deriving any city taxable income, indicate so by 
                                                               filling in the date of your retirement. 

                                                 2. If the taxpayer is not retired but did not receive any city taxable income for the year in question, circle the 
                                                               appropriate response and/or describe the nature of the income in the space provided.  This exemption is for 
                                                               one year only.  Form “Declaration of Exemption” must be completed for each subsequent year. 

                                                 3. If you were under the age of sixteen (16) for the entire year in question, indicate so by filling in your date 
                                                               of birth.  This exemption must be accompanied by proof of age (e.g. a photocopy of a birth certificate or 
                                                               driver’s license showing date of birth.  Parents of a Minor: If your child received earned income, and is 
                                                               under the age of 16, please circle #3 on the form, note the birth date, and submit above documentation. 

                                                 4. If the taxpayer was an active member of the U.S. Armed Forces for the entire year in question, circle #4.  
                                                               Documentation verifying the dates of active duty status during the year in question must be attached.  This 
                                                               exemption is for one year only and Form “Declaration of Exemption” must be completed for each 
                                                               subsequent year. 

                                                 5. If the taxpayer did not reside in the City of Warren for which the exemption is being claimed at all during 
                                                               the year in question, indicate so by filling in the date the taxpayer moved in or out of the municipality.  
                                                               Please attach proof of move such as a copy of your current year municipal income tax return, most recent 
                                                               lease or proof of the purchase date of your new residence. 

                                                 6. If the taxpayer has filed jointly with his/her spouse, indicate so by filling in the name of the spouse and 
                                                               provide his/her Social Security Number.  If in a subsequent year, a married couple elects to file separately, 
                                                               it shall be the responsibility of each spouse to obtain and file a separate return. 

estate should indicate the taxpayer’s            7. If the taxpayer in question is deceased, the Executor of the taxpayer’s 
                                                               date of death and supply a copy of the death certificate. 

                                                 In all cases where the taxpayer is eligible for exemption, the taxpayer must provide his/her social security 
                                                 number, name, address, and phone number. 

                                                 This Exemption Form is not valid and will not be processed without the taxpayer’s signature and date. 

                                                                                  WARREN CITY INCOME TAX DEPARTMENT 

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