Department of                        Calendar Year
 hio         Taxation
                                                                                                    10211411

                            Request for Exclusion from the Income  
                            Tax Return Electronic Filing Requirement

Paid preparers may use this form to request an exclusion from the requirement to transmit income tax returns 
electronically. Do not complete this form if you prepared fewer than 11 original returns in the previous calendar 
year. See R.C. 5747.082. 

Failure to provide all requested information may result in denial of your request. The Department will send you written 
notice of its decision.

 Business name                                                                    PTIN

 Business address, City, State and ZIP code

 Contact name                                                                     Contact number 

 FEIN                                      # of original returns prepared last calendar year

Reason(s) for requesting an exclusion from electronic filing:

Sign Here (required)                                                                        Date

 Federal Privacy Act Notice: Because we require you to provide us with a Social   Mail this form to:
 Security number, the Federal Privacy Act of 1974 requires us to inform you that  Ohio Department of Taxation
 providing us with your Social Security number is mandatory. Ohio Revised Code    Electronic Filing Unit
 sections 5703.05, 5703.057 and 5747.08 authorize us to request this information. P.O. Box 2476
 We need your Social Security number in order to administer this tax.             Columbus, OH 43216-2476

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