Do I need a notary for the Individual Declaration of Exemption?

No. The form has signature and date lines but no notary block. It may require supporting documents for the reason selected, such as tax return pages, proof of a new address, or a death certificate.

How do I submit the Individual Declaration of Exemption?

Mail the completed declaration to Regional Income Tax Agency, P.O. Box 94801, Cleveland, Ohio 44101-4801. The form says not to attach a refund request; it directs refund requests to a separate Form 10A.

What attachments might this declaration require?

Attachments depend on the exemption selected. The form lists federal tax return pages for some reasons, proof of a new address after moving from a RITA municipality, and a death certificate when the taxpayer or spouse is deceased.

Jackson Center, OH · Shelby County

No notary required

Individual Declaration of Exemption

This form lets an individual declare why they believe they do not need to file a municipal income tax return for a tax year.

What this form is

Use this declaration to explain why you believe you are not required to file a municipal income tax return for the tax year shown. It asks for taxpayer and spouse details, address and income or exemption information, and signatures and dates. Depending on the reason selected, the form requests supporting documents such as federal tax return pages, proof of a new address, or a death certificate.

Who needs it

An individual who believes they are exempt from filing a municipal income tax return for the year shown may submit this declaration.

How to submit it

Mail the completed declaration to Regional Income Tax Agency, P.O. Box 94801, Cleveland, Ohio 44101-4801.

About notarization

This declaration is signed without a notary; the form asks the taxpayer and, when applicable, spouse to sign and date it.

How to submit this form

1
Download the Form
Download the Individual Declaration of Exemption PDF.
2
Complete the Declaration
Enter the tax year and requested taxpayer and spouse information, then circle the statement that best applies.
3
Gather Required Attachments
Include the supporting documents listed for the exemption you select, if applicable.
4
Sign and Mail the Form
Sign and date the declaration, then mail it to the Regional Income Tax Agency address printed on the form.

Frequently asked questions

What is the Individual Declaration of Exemption?: It is a form for declaring why you believe you are not required to file a municipal income tax return for the tax year shown. It asks for your details, the reason for exemption, and your signature.
Do I need a notary for the Individual Declaration of Exemption?: No. The form has signature and date lines but no notary block. It may require supporting documents for the reason selected, such as tax return pages, proof of a new address, or a death certificate.
How do I submit the Individual Declaration of Exemption?: Mail the completed declaration to Regional Income Tax Agency, P.O. Box 94801, Cleveland, Ohio 44101-4801. The form says not to attach a refund request; it directs refund requests to a separate Form 10A.
What attachments might this declaration require?: Attachments depend on the exemption selected. The form lists federal tax return pages for some reasons, proof of a new address after moving from a RITA municipality, and a death certificate when the taxpayer or spouse is deceased.

Need something notarized?

This Individual Declaration of Exemption doesn’t need a notary — but if you have another Jackson Center form that does, a commissioned online notary can help.