Do not staple or paper clip. Use only black ink and UPPERCASE letters. 

                                            IT 10 – Ohio Income Tax 

                   Rev. 9/19                        Information Notice                                                   07120102
                                                                      2016
                                                                      Taxable Year
                For use only by individuals claiming to owe no Ohio individual income tax for the year.
                             This notice must be filed by the filing deadline for the Ohio IT 1040.
Taxpayer SSN (required)                                      Spouse’s SSN (only if joint notice)

Your first name                                              M.I. Last name

Spouse's first name (only if joint notice)                   M.I. Last name

Address 

City                                                                          State             ZIP code   Ohio county (first four letters)

Foreign country (if the mailing address is outside the U.S.)                  Foreign postal code

Filing Status – Check one (as reported on federal income tax return)
  Single, head of household or qualifying widow(er)          Married filing jointly             Married filing separately

                             I am not required to file an Ohio income tax return because:
1.      I moved out of the state of Ohio before Jan. 1st of the taxable year, 3.    I do not have a tax liability on line 8c of my Ohio IT 1040.
        and I had no income in Ohio during the taxable year.
        I moved to the state of                                               4.    I was in the military stationed in Ohio during the taxable year and 
                                                                                    my only source of income earned in Ohio is from the military, but 
                                                                                    I am a resident of the state of
        Date moved           /             /
2.      During the taxable year I was a full-year resident of one of the 
        following states, and I had no taxable income in Ohio other           5.    I am using an Ohio address for mailing purposes only.
        than compensation (wages, salaries or tips) from unrelated 
        employers:                                                            6.    I am a civilian spouse of a nonresident service member on duty 
                                                                                    stationed in Ohio, solely because of military orders. My state of 
         Kentucky        Indiana            West Virginia                           residence is
         Michigan        Pennsylvania

Sign Here (required): Sending in this notice does not constitute the filing of an income 
tax return. I have read this notice. Under penalties of perjury, I declare that, to the best of my 
knowledge and belief, the notice information is true, correct and complete.
                                                                                                                         Mail to: 
Your signature                                                       Date (MM/DD/YY)                      Ohio Department of Taxation
                                                                                                                         P.O. Box 2476
                                                                                                                         Columbus, OH 43216-2476
Spouse’s signature                                                   Phone number

 Preparer’s name (print name)                                         Phone number
        Check here to authorize your preparer to discuss this notice with Taxation.
                                                    Federal Privacy Act Notice
      Because we require you to provide us with a Social Security number, the Federal Privacy Act of 1974 requires us to inform you that 
      providing us with your Social Security number is mandatory. Ohio Revised Code sections 5703.05, 5703.057 and 5747.08 authorize 
      us to request this information. We need your Social Security number in order to administer this tax.