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Regional Income Tax Agency 800.860.7482
Declaration of Exemption 440.526.5332 TTD
Do not use staples, tape or glue ritaohio.com
Before you begin: You cannot use this form to request a refund. To request a refund, use Form 10A available at ritaohio.com.
Did you Know? You can go to ritaohio.com and FastFile or login to MyAccount and file your exemption electronically.
Your social security number Spouse’s social security number Tax Year(s) ________________________
Your first name and middle initial Last name This request is for (check only one box):
All tax years beginning with the year above
If a joint return, spouse's first name and middle initial Last name
For the tax year above only
CURRENT MAILING address (number and street) Apt #
Mail Declaration to:
REGIONAL INCOME TAX AGENCY
City, state, and ZIP code P.O. BOX 94801
Cleveland, Ohio 44101-4801
Check the applicable reason(s) below and provide the information and documentation indicated for that reason.
1. NO MUNICIPAL TAXABLE INCOME for the entire year. Municipal taxable income includes W-2 income, Federal
Schedule C, E, F, 1099-MISC/NEC or Form 4797 income. If you have municipal taxable income and do not meet
other exemptions below, your income is not exempt and you must file a RITA Form 37. Go to ritaohio.com. If you have a
joint account, you may only check reason 1 if both you and your spouse have no municipal taxable income.
Enclose pages 1 & 2 and Schedule 1 of your Federal Form 1040.
2. US ARMED FORCES INCLUDING RESERVE COMPONENTS AND THE NATIONAL GUARD. If you would have met
the requirements of reason 1 except you received one or more W2 forms, but those W2 forms reported only military pay
and allowances for the year, check this reason for your exemption. Civilian employees of the armed forces are not eligible
for this exemption.
3. AGE EXEMPT for the entire year. Enter your date of birth: __________________
MM/DD/YYYY
Enclose a copy of your Birth Certificate or Driver’s License
4. RETIRED for the entire year and not receiving W2 income, self-employment income, consulting income, rental income,
farm income, or gambling winnings.
Enclose pages 1 & 2 of Federal Form 1040 / 1040-SR and Federal Schedule 1. Date Retired: __________________
MM/DD/YYYY
Enclose spouse’s pages 1 & 2 of Fed Form 1040 / 1040-SR and Fed Schedule 1. Date Retired: __________________
MM/DD/YYYY
5. NON-RESIDENT for the entire year with no self-employment or rental income earned in the municipality.
Enter prior address here: _____________________________________________. Date of Move: __________________
MM/DD/YYYY
6. DECEASED. Enclose a copy of the taxpayer’s death certificate. Date of Death: __________________
MM/DD/YYYY
Enclose a copy of the spouse’s death certificate. Spouse’s Date of Death: __________________
MM/DD/YYYY
7. FILING JOINTLY. Check this reason if you are not exempt and are filing jointly. Complete your spouse’s information in
the address section of this form.
Under penalties of perjury, I declare that this Declaration of Exemption is true, correct and complete. I further acknowledge that should my income change
to include municipal taxable income, I will be required to file a municipal tax return for all tax years that I received municipal taxable income.
Your signature Date Contact phone number
Sign
Here Spouse's signature Date Alternate phone number
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