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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.
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