BERKHEIMER TAX ADMINISTRATOR
PO Box 22170
Lehigh Valley, PA 18002-5175
VOLUNTARY STATEMENT OF FINANCIAL STATUS
In support of
REQUEST FOR DEFERMENT OF PER CAPITA TAX PAYMENT FOR SAUCON VALLEY
July 1, 2016 to June 30, 2017
Full Name ________________________________
Telephone No. _____________________________
Present Occupation __________________________
Previous Occupation _____________________________
Present Employer ____________________________
Previous Employer _____________________________
Present Total Annual Income
$___________ is received from the following:
Wages:___________ Social Security Income: _________
List Other Income Sources: ________________________________________
Marital Status ________
Number of Dependents _______
I request deferment of payment of my Per Capita taxes for the 2016-2017 school year.
Note: "Any single individual eighteen (18) years of age and older, with a total income from all sources of ten
thousand ($10,000) dollars or less, or a married couple with a total combined income from all sources of twenty
thousand ($20,000) dollars or less, be exonerated from the payment of the Per Capita Tax under Act 511 and
under School Code Section 679."
This application exonerates any person eighteen (18) years of age and older from the payment of Per Capita taxes for the
2013-2014 school year only. In order to be eligible for exoneration, an application must be completed every year.
Documentation must be attached to the application before board approval:
1. A copy of a prior year’s federal income tax return, or if a federal return was not required to be filed, copies of
social security, disability or other non-taxable income statements
2. A copy of proof of attendance or registration to college or school as a full time student for the current year.
I/We agree to notify the Berkheimer Tax Administrator in the event of any change in my/our financial status, making me/us
ineligible for tax deferment.
I/We declare under penalties of perjury, that the above statements are true and correct to the best of my/our information
ACCT NO. ______________
Mr. Mrs. Ms. _____________________________________________________
Please attach Per Capita Bill(s) to this form
*If couple applies for exoneration, two (2) signatures will be required.
APPROVED _______________ NOT APPROVED ___________________
IMPORTANT: FILL IN THIS FORM COMPLETELY
THIS FORM MUST BE RECEIVED BY THE BERKHEIMER TAX ADMINISTRATOR ON OR BEFORE
APRIL 1, 2017