City of Lakewood                                              
Division of Municipal Income Tax                                                           This exemption form may not be 
                                                                                           used by those engaged in business, 
12805 Detroit Ave                          Individual                                      including those receiving, self-
Lakewood, OH 44107                                                                         employment, Federal K-1 
Telephone: (216) 529-6620            Declaration of Exemption                              distributions or rental property 
Fax: (216) 529-6099                  Tax Year: ___________                                 located in The City of Lakewood 
www.ci.lakewood.oh.us 
    
   The City of Lakewood currently requires mandatory filing of City tax returns.  If you meet one of the following 
   exemptions, the filing of this Declaration of Exemption will serve to meet the filing requirement. 
    
 Social Security Number     Spouse’s Social Security Number 
  
  Last Name           First Name       Initial               Spouse’s Last Name            First Name    Initial   
   
  Present Address                Apt #                                 City                   State         Zip Code 
   
  Please circle one of the following and attach documentation when necessary. 
  
 1. I am permanently retired as of ______ / _______ / _______ 
  
 2. No taxable income for all of the tax year ___________.   
  
 3. I was under 18 years of age for the entire year of ___________.  Date of Birth:  ______ / ______ / ______ 
    (Please attach documentation-copy of Birth Certificate or Driver’s License) 
     
 4. Active military duty for the entire year of _________. 
  
 5. I did not reside in the City of Lakewood for any part of the year.  Date moved out of Lakewood: _____ / _____ / _____ 
    (Please attach proof of move such as lease or proof of purchase date). 
  
 6. Full time student living on campus or in off campus housing and residing in the City of Lakewood for less than sixteen 
    (16) consecutive weeks during the taxable year of ________ (Please attach proof.  See Instructions for acceptable 
    documentation). 
  
 7. I am filing jointly with my spouse_______________________ Social Security #____________________. 
  
 8. Taxpayer is deceased.  Date of Death: _____ / _____ / _____.  (Please attach a copy of the death certificate). 
  
 I hereby declare the information supplied above to be true, correct and complete 
    
   S ig n a tu r e                                                Date     
                                                                                   
 Spouse’s Signature      Date      
                                                                                                          
 Telephone Number       
    
                                           Mail completed form to: 
                                           City of Lakewood 
                                       Division of Municipal Income Tax 
                                     12805 Detroit Ave. Lakewood, Ohio 44107 
                                       Form may be faxed: 216.529.6099 

                          INSTRUCTIONS FOR FORM DECLARATION OF EXEMPTION 
 
If you were a wage earner, were self-employed, owned rental property, had lottery or gambling winnings, or received a 
distribution from a partnership or s-corporation 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, receiving only pension income, social security income and dividends 
   or interest income and do not anticipate deriving any city taxable income, indicate so by filling in the date of your 
   retirement.  
 
2. If the taxpayer is not retired but did not receive any city taxable income for the year in question, circle box 2 and 
   describe the nature of the income in the space provided.  This exemption is for one year only and form  “Declaration 
   of Exemption” must be completed for each subsequent applicable year. 
 
3. 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 of driver’s license) 
   Parents of Minors - If your child has received earned income and are under the age of eighteen (18), please 
   check box 3 on the front of this page, note the birth date and submit above documentation. 
    
4. If the taxpayer was an active member of the U.S. Armed Forces for the entire year in question, circle Box 4.  
   Documentation verifying the dates of active duty status were during the tax year in question must be attached.  This 
   exemption is for one year only and Form “Declaration of Exemption” must be completed for each subsequent year. 
    
5. If the taxpayer did not reside in the City of Lakewood for which the exemption is being claimed at all during the year 
       in question, indicate so by filling in the date the taxpayer moved in or out of the municipality.  Please attach proof of  
       move such as a copy of your current year municipal income tax return, most recent leases or proof of the purchase date  
       of your new residence.    
 
6. Those individuals domiciled in the City of Lakewood who attended an accredited college or university for the entire 
   year and lived on campus or in off campus housing and did not live in the City of Lakewood more than sixteen (16) 
   consecutive weeks during the year will be considered exempt. Proof must be submitted with this form and may consist 
   of transcript of grades, registration forms or billing statements.  Be sure to include proof for each quarter or semester of 
   the tax year and circle box 6 on this form.  This exemption is for one year only and Form “Declaration of Exemption” 
   must be completed for each subsequent year. 
 
7. If the taxpayer has filed jointly with his/her spouse, indicate so by filling in the name of the spouse and provide his/her 
   Social Security Number.  If in a subsequent year, a married couple elects to file separately, it shall be the responsibility 
   of each spouse to obtain and file a return. 
 
8. If the taxpayer in question is deceased, the executor of the taxpayer’s estate should indicate the taxpayer’s date of 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.