Form 83-A-15 - Refund Petition
ADVERTISEMENT
1CITY OF PHILADELPHIA • • • • DEPARTMENT OF REVENUE
REFUND PETITION
For all refunds except Individual Employee Wage Tax
SEE INSTRUCTIONS ON REVERSE. CLEARLY PRINT OR TYPE ALL INFORMATION.
PETITION NUM BER
1. PETITIONER'S NA ME (First Name, Middle Initial, Last Name)
(Of fice use only)
2. BUSINE SS NA ME
4. SOCIA L SECURITY NUMBER
-
-
3. MAILING A DDRESS
5. FEDERAL EMPLOY ER IDE NTIFICATION NO.
-
CITY
STATE
ZIP CODE
6. PROPERTY ADDRESS (For Real Estate, Water and Business Use & Occupancy Refunds Only)
7. PHONE NUMBER
FAX NUMB ER
E-MAIL ADDRESS
8. RE FUND TY PE (Check all that apply and list below. For Wage Tax, Rea l Estate Tax and Other, see i mportant i nformation on reverse.)
Wage Tax
Business Use & Occupancy Tax
Business Privilege Tax
Net Prof its Tax
Parking Tax
Real Estate Tax
Liquor Tax
Water/Sewer
Hotel Tax
A musement Tax
School Income Tax
Other (specify)________________
A . TA X A CCOUNT
B. TA X Y EA R OR
C. A MOUNT OF
A . TA X A CCOUNT
B. TA X Y EA R OR
C. A MOUNT OF
NUMBER
PERIOD/Y EA R
CLA IM
NUMBER
PERIOD/Y EA R
CLAIM
9. RE ASON FOR THIS REFUND PETITION
I HEREBY CERTIFY that the statements contained herein and in any supporting schedule or exhibit are true and correct to the best of my
knowledge and belief. I understand that if I knowingly make any false statements herein, I am subject to penalties as prescribed by law.
PETI TIONER'S S IGNATURE
DATE
MAIL COMPLETED REFUND PETITION TO:
REFUND INFORMATION:
PHILADELPHIA DEPARTMENT OF REVENUE
TELEPHONE: 215-686-6574, 6575, 6578
REFUND UNIT, ROOM 580
FAX: 215-686-6228
1401 JOHN F. KENNEDY BOULEVARD
E-MAIL: revenue@phila.gov
PHILADELPHIA, PA 19102
INTERNET: phila.gov/revenue
OR FAX TO: 215-686-6228
83-A-15 (Rev. 3/ 2006)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial