City of Lakewood 
                                             Division of Municipal Income Tax 
                                   12805 Detroit Ave., Suite 1    Lakewood, Ohio 44107 
                                       Telephone: (216) 529-6620      Fax: (216) 529-6099 
                                                       www.lakewoodoh.gov 
 
                                INDIVIDUAL DECLARATION OF EXEMPTION 
                                                                       
                                                       Tax Year: _______ 
 
The City of Lakewood is a mandatory filing city requiring all residents 18 years of age and over to file a tax return or an appropriate 
exemption form for each year or partial year lived in Lakewood.   
 
PLEASE NOTE:If you were a wage earner; were self-employed; owned property for which you declared income or a loss on 
your Federal return; had lottery or gambling winnings; or received a taxable distribution from a partnership, S-corporation, 
or trust, you cannot use this exemption form and must file a tax return. 
 
Primary Name: __________________________________                          Primary SSN: _________________________ 

Spouse Name: ___________________________________                          Spouse SSN: __________________________ 

Present Address: ____________________________   Apt. Number: _____     City: _________________________  

State: ______     Zip Code: _______________      Telephone Number: (____)______-_______________ 

Please circle one of the following and attach documentation when necessary. 
 
 1.    I am permanently retired as of ______ /______   ______    /     . 
 2.    I am permanently disabled as of ______ /______     ______    /    . 
 3.    No taxable income was earned for all of tax year _______.   Please explain:    ______                                          . 
 4.    I was under 18 years of age for the entire year of _______.  Date of Birth: ______ /______     ______    / . 
       Proof is attached (see instructions). 
 5.    Active military duty for the entire year of _______. 

 6.    I did not reside in the City of Lakewood for any part of the year.  Proof is attached (see instructions).  
       Date of move from Lakewood:  ______ /______        ______    /     
 7.    I am filing jointly with my spouse, ________________________. Social Security #: ____________________                                  
 8.    Taxpayer is deceased.  Date of Death: ______ /______ ______    /        (Please attach copy of death certificate)  
                                                                           
                      If you need tax forms or assistance in answering this notice, please call (216) 529-6620. 
 
THE UNDERSIGNED DECLARES THAT THIS STATEMENT IS TRUE, CORRECT, AND COMPLETE FOR THE 
ABOVE MENTIONED YEAR. 
 
Primary Signature:  _________________________________________________ Date:                   ______ /______      ______    /            
 
Spouse Signature:   _________________________________________________ Date: ______ /______                        ______    /            
 
This exemption form is not valid and will not be processed without the taxpayer’s signature and date. 

                 INSTRUCTIONS FOR FORM DECLARATION OF EXEMPTION 
                                                             
If you were a wage earner; were self-employed; owned property for which you declared income or a loss on your Federal 
return; had lottery or gambling winnings; or received a taxable distribution from a partnership, S-corporation, or trust, 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; received only pension income, social security income, dividends, or interest 
    income; and do not anticipate deriving any income taxable to Lakewood, indicate so by circling option 1 on the front of this 
    page. Please also fill in the date of your retirement. This exemption is for one year only, and additional declarations must 
    be completed for each subsequent applicable year.  
 
 2. If you were disabled for the entire year in question; received only disability income, social security income, dividends, or 
    interest income; and do not anticipate deriving any income taxable to Lakewood, indicate so by circling option 2 on the front 
    of this page. Please also fill in the start date of your disability. Please attach proof of disability (e.g. your disability award 
    letter for the tax year in question, page one of your Federal 1040/1040A/1040-EZ). This exemption is for one year only, 
    and additional declarations must be completed for each subsequent applicable year.  
 
 3. If you are not retired or disabled but did not receive any income taxable to Lakewood for the year in question, indicate so by 
    circling option  3  on the front of this page. Please also fill in the applicable tax  year and a short explanation  of the 
    circumstances (e.g. disability, unemployment, no employment, etc.). This exemption is for one year only, and additional 
    declarations must be completed for each subsequent applicable year. 
 
 4. If you were under the age of eighteen (18) 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).  
    NOTE: Parents of minors – If your child has received earned income and is under the age of eighteen (18), please 
    circle option 4 on the front of this page, note the birth date in the applicable space, and submit the abovementioned 
    documentation. 
 
 5. If you were an active member of the U.S. Armed Forces for the entire year in question, please circle option 5 on the front of 
    this page. Documentation verifying that the dates of active duty status were during the tax year in question must be attached. 
    This exemption is for one year only, and additional declarations must be completed for each subsequent applicable 
    year. 
 
 6. If you did not reside in the City of Lakewood at all during the year in question, indicate so by circling option 6 on the front of 
    this page. Please also fill in the date of your move into or out of Lakewood. Please attach proof of your move (e.g. a copy of 
    your non-Lakewood municipal income tax return filed  with your resident municipality during the  year in question, a 
    lease/rental agreement or closing statement confirming the claimed move-in or move-out date, or proof of an address change 
    with the U.S. Postal Service). 
 
 7. If you filed jointly with your spouse, indicate so by circling option 7 on the front of this page. Please also fill in the name of 
    your spouse and provide his/her social security number. 
    NOTE: If a married couple elects to file separately in a subsequent year, it shall be the responsibility of each spouse to 
    obtain and file a return with our office. 
 
 8. If the taxpayer in question is deceased, the executor of the taxpayer’s estate should indicate so by circling option 8 on the 
    front of this page. The executor should also indicate the date of the taxpayer’s 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.