2013CLEVELANDCOLUMBUSYOUNGSTOWNTDDREGIONAL INCOME TAX AGENCYP.O. BOX 94801Cleveland, Ohio 44101-4801800-860-7482866-721-7482866-750-7482440-526-5332INDIVIDUAL DECLARATION OF EXEMPTIONSOCIAL SECURITY NUMBERSPOUSE'S SOCIAL SECURITY NUMBERFIRST NAMEM.I.LAST NAMESPOUSE'S FIRST NAMEM.I.SPOUSE'S LAST NAME (IF DIFFERENT)ADDRESS NUMBERSTREET NAMECITY NAMESTATEDAY PHONEZIP CODEEVENING PHONEI AM NOT REPORTING TAXABLE INCOME FOR 2013 BECAUSE:1.I had NO TAXABLE INCOME for the entire year of 2013 (Attach a copy of your Federal 1040 Form)2.I was a member of the ARMED FORCES, including the National Guard, of the United States for all of 2013and had no other taxable income. (This does not include civilians employed by the military)3.I was UNDER AGE 18 for all of 2013……………………………………………………………………..... Date of Birth:(Attach copy of Birth Certificate or Driver’s License. For exceptions, see special notes)____/____/____MO DAY YR4.I am a RETIRED individual receiving only pension, social security, interest,dividends or other non-taxable income for all of 2013 …………………………………………………….DateRetired:(Attach a copy of page 1 of your 2013 Federal 1040 return)____/____/____MO DAY YR5.Prior to January 1, 2013, I moved from a RITA municipality………………………………………………Date ofMove:(indicate previous address below)____/____/____MO DAY YR__________________________________________________________________________________________PREVIOUS ADDRESS6.Taxpayer is Deceased…………………………………………………………………………………………Date of Death:(Please enclose copy of Death Certificate)7.I am filing a 2013 RITA return Jointly, with my Spouse. ______________________________________________Spouse’s Name____/____/____MO DAY YR______-_____-_________Spouse’s SSN________________________________________ ________________________________________SIGNATUREDATESPOUSE’S SIGNATUREDATETHE ABOVE SIGNED DECLARES THAT THIS RETURN IS TRUE, CORRECT AND COMPLETE FOR THE TAX YEAR 2013.