Taxable Year      IT Waiver 
                                                                                                                        Rev. 8/18 
                I~ae:a~~~ent of                 IIIII III IIIIIllII IIIIIII                          I I I I I 
                                                          10211411 

                                        Individual Taxpayer Waiver 
                           for Preparer’s Electronic Filing Requirement 
                    Include the completed and signed IT Waiver with your Ohio income tax return. 

 Your name                                                                         SSN 

 Spouse’s name                                                                     SSN (if filing jointly) 

 Address, city, state and ZIP code 

 Purpose of This Form:     Atax return preparer who prepares more than 11 Ohio income tax returns for the calendar year 
 must use an electronic method to file.  If an individual taxpayer is unable or unwilling to file electronically for a given tax 
 year, the taxpayer must include a signed IT  Waiver with the Ohio income tax return to exclude his or her return from the 
 preparer mandate. 

 Part I – Taxpayer Declaration 

 I declare that I do not want the tax return preparer to file my Ohio income tax return electronically. 

 Your signature                          Date                  Spouse’s signature                                  Date 
   (if joint return, BOTH must sign)  

 Part II – Paid Tax Preparer Information 

 Preparer’s/transmitter’s name 

                                   or                                              or 
 Preparer’s tax identification #        Federal employer identification #          SSN (last four digits) 

 Firm’s name (or yours, if self-employed) 

 Address, city, state and ZIP code 

 IRS electronic filing reject code 

                                          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.