City of Columbus                                            
Income Tax Division                                        Line 5: If the taxpayer is not retired but did not receive 
                                                                   any  city  taxable  income  for  the  year  in 
                                                                   question,  indicate so  by checking Box 5 and 
Instructions for                                                   describing  the  nature  of  the  income  in  the 
                                                                   space provided.  This exemption is for  one 
Form EX-1                                                          year only and Form EX-1 must be completed 
                                                                   for each subsequent applicable year. 
                                                            
Declaration of Exemption                                    
                                                           Line 6: If the taxpayer  was an active member of the 
only for Residents of Harrisburg and                               U.S.  Armed Forces for the  entire year  in 
Marble Cliff                                                       question, indicate so by checking Box 6.   This 
                                                                   exemption is for one year only and Form EX-1 
 
                                                                   must  be  completed  for  each  subsequent 
For use in preparing                                               applicable year. 
                                                            
               Returns 
2017                                                        
                                                           Line 7: If the  taxpayer anticipates or has filed jointly 
                                                                   with his/her spouse, indicate so by filling in 
You must be a resident of Harrisburg or Marble Cliff  to           the name of the spouse.   If in a subsequent 
use this form.                                                     year,  a  married  couple  elects  to  file 
                                                                   separately, it shall be the responsibility  of 
If you were a wage-earner, were self-employed, owned               each spouse to obtain and file a return. 
rental property, or derived any other city taxable income,  
you are not exempt from the  annual filing requirement      
and may not use this form.                                 In all cases where the taxpayer is eligible for exemption, 
                                                           the taxpayer should provide his/her social security 
                                                           number, name, address and phone number. 
Line 1: 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    THIS EXEMPTION FORM WILL NOT BE PROCESSED 
        must be accompanied by proof of age (e.g. a        AND IS NOT VALID WITHOUT  THE TAXPAYER’S 
        photocopy of a birth certificate or driver’s       SIGNATURE. 
        license).                                           
                                                            
                                                           Completed forms should be directed to: 
Line 2: If you were retired during the year in question,    
        receiving  only  pension  income,  and  do  not            Columbus Income Tax Division 
        anticipate  deriving  any  city  taxable  income,          PO Box 182437 
        indicate so by filling in the  date of  your               Columbus, OH 43218-2437 
        retirement. Those individuals of or near                                                             
        retirement  age  who  received  only  city                                                 Rev. 6/16/17 
        nontaxable  income  (e.g.  interest,  dividends)                                                     
        may also claim this exemption by filling in the 
        date that the individual  discontinued earning 
        city taxable income. 
 
Line 3: If the taxpayer did not reside  in the 
        municipality for which the  exemption is being 
        claimed  at all  during  the  year  in question, 
        indicate so by filling in the date the taxpayer 
        moved out of the municipality. 
 
Line 4: If the taxpayer in question is deceased, the 
        executor  of  the  taxpayer’s estate should 
        indicate the taxpayer’s date of death.