EXEMPTION FORM 2022
                                                    (See General Information)
                                                         CITY OF CANTON
                                                INCOME TAX DEPARTMENT
                                                             P.O. Box 9951
                                                             Canton, Ohio 44711
                                                         cantonincometax.com

You may not be required to file a city income tax return. Complete this form and return it to our office
                                by April 1 th,8 and you will not be considered a delinquent taxpayer.

ACCOUNT #_______________________________________________________________________________________________________________________

SOCIAL SECURITY # ______________________________________________  NAME ___________________________________________________________

SOCIAL SECURITY # ______________________________________________  SPOUSE _________________________________________________________

ADDRESS _________________________________________________________________________________________________________________________

CITY  ___________________________________________________________________  STATE  ________________________   ZIP _____________________

TELEPHONE NO.  __________________________________________________________________________________________________________________

Upon turning 65 years old, please submit this form and proof of age if there is no taxable income so your account can be 
closed. (Copy of Birth Certificate, Driver’s License) - REQUIRED.

Please indicate birthdate:        Yours

                                Spouse

I am not required to file a 2022 return because:
1. My sole income is derived from the following source(s):
                           A.   Social Security Benefits             J.          Military Service
                           B.   Pension                              K.          A.D.C.
                           C.   Interest Income                      L.          General Public Assistance
                           D.   Dividend Income                      M.          Unemployment Compensation
                           E.   Total Permanent Disability           N.          65 yrs. old or older with wages,    
                           F.   Workers Compensation                             commission or other compensation 
                                                                                 earning less than $10,000.
                           G.   Alimony                             *O.          65 yrs. old or older with rental and/or
                           H.   No Income                                        business activity earning less than
                           I.   Other (Please Explain)                           $10,000. (Attach Schedule E and/or
                                                                                 Schedule C as filed.)
                           ____________________________
2. Taxpayer Deceased in previous year

Date Deceased

3. Did not live in city of Canton in previous year.

Date Moved Out
I CERTIFY I HAVE EXAMINED THIS RETURN (INCLUDING ACCOMPANYING SCHEDULES AND STATEMENTS) AND TO THE BEST OF MY
KNOWLEDGE, I BELIEVE IT IS TRUE, CORRECT, AND COMPLETE.

Signature __________________________ Date ___________________            Spouse __________________________ Date ___________________

*PLEASE NOTE: The Exemption Form may be used only if a senior citizen’s net income is less than ten thousand dollars ($10,000).
Seniors will need to continue filing tax returns or Exemption Forms as long as they engage in rental and/or business activity.