City of Columbus, Income Tax Division
Form                    Declaration of Exemption ONLY for residents of Harrisburg and Marble Cliff
EX-1

This form is NOT to be used as an Application for Refund.  

     SOCIAL SECURITY NUMBER                                  SPOUSE'S SOCIAL SECURITY NO.

                                                                                                                                                                      This exemption 
                                                                                                                                                                   form may not be 
LAST NAME                                                                         FIRST NAME                                                       INITIAL
                                                                                                                                                                       used by those 
                                                                                                                  INITIAL                                              engaged in 
SPOUSE’S FIRST NAME
                                                                                                                                                                   business, including 
STREET ADDRESS                                                                                                                                          APT        those receiving self-
                                                                                                                                                                       employment or 
CITY                                                                      STATE                                                                  ZIP                   rental income.
                             0

             I AM NOT REQUIRED TO FILE A CITY TAX RETURN BECAUSE:

1.  I was UNDER 18 years of age for the entire year.                                                                                                  DATE OF BIRTH:                                 1
     (Attach documentation)                                                                                                                                                      MO       DAY       YR
2.  I am a retired person receiving only pension income
                                                                                                                                                      DATE RETIRED:                                  2
    or other nontaxable income for the year.
                                                                                                                                                                                 MO       DAY       YR
3.  I did not reside in the city/village of
     for the entire year of                                                                                                                                                                          3
                                                                                                                                                       DATE OF MOVE:
                                                                                                                                                                                 MO       DAY       YR

4.  Taxpayer is DECEASED.                                                                                                                             DATE OF DEATH:                                 4
                                                                                                                                                                                 MO       DAY       YR
5.  I had NO TAXABLE INCOME for the entire year of                                                                                                    (Check this Box)............................   5
          .Income Source (Social Security, Welfare, etc.)                                                                                              (Current Year Exempt Only)

6.  I was a member of the ARMED FORCES, including the                                                                                                 (Check this Box)............................   6
    National Guard, of the UNITED STATES for the entire year.                                                                                          (Current Year Exempt Only)
    (This does not include civilians employed by the military).

7.  I am FILING JOINTLY with my spouse whose name is:                                                                                                                                                7

I hereby declare the information supplied above to
             be true, correct and complete.                                                                                                            Mail completed form to:

                                                                                                                                                       COLUMBUS INCOME TAX DIV.
Signature                                                                                    Date
                                                                                                                                                       PO Box 182437
                                                                                                                                                       Columbus, Ohio 43218-2437
Spouse’s Signature                                                                     Date

Telephone Number
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Rev.  6/16/17