"Application For Exoneration" School Per Capita Tax Form
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1SALISBURY TOWNSHIP SCHOOL DISTRICT
1140 SALISBURY ROAD
ALLENTOWN, PA 18103
(Do not return application to this address, see bottom of form)
Exoneration must be filed
Prior to December 31 of
Fiscal taxing year.
“APPLICATION FOR EXONERATION”
SCHOOL PER CAPITA TAX
YEAR 20____________
Bill #_________________
NAME _______________________________________________________________________________________
DATE OF BIRTH ________________________ SOCIAL SECURITY NUMBER __________________________
ADDRESS ____________________________________________________________________________________
REASON FOR REQUEST FOR EXONERATION ____________________________________________________
(Please refer to the list below for acceptable reasons)
ACCEPTABLE REASONS FOR EXONERATION
1. Paid to tax collector before contact
7. Under 18 years of age
2. Paid in another taxing district
8. Exonerated per letter from taxing authority
[1]
3. Moved – Left no address
9. Insufficient earnings
4. Deceased
under $5,000 per person annually
5. Non-resident
10. Statute of limitations expired
[2]
6. Double assessment
11. Active Military Duty
[1]
IF INSUFFICIENT EARNINGS (#9) IS USED, PLEASE PROVIDE THE FOLLOWING INFORMATION:
Annual income (reported to IRS as adjusted gross income)
$ _________________
$ _________________
SALARY OR WAGE
NET RENT FROM PROPERTY
$ _________________
$ _________________
PENSION/SOCIAL SECURITY
INVESTMENTS
$ _________________
$ _________________
TRADE OR BUSINESS
PROFESSIONAL INCOME
$ _________________
$ _________________
PUBLIC ASSISTANCE
OTHER
(ex. dividends, interest, etc.)
$ _________________
TOTAL
[2]
IF ACTIVE MILITARY DUTY (#11) IS USED, PLEASE PROVIDE DEPLOYMENT DATE
_________________. YOU MUST REAPPLY EACH YEAR FOR THIS EXEMPTION.
List additional information on a separate sheet which you believe will support your claim for exoneration.
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I, __________________________________, hereby swear (or affirm) that the above information is true and correct to
the best of my knowledge and belief and any misinformation stated above shall cause my exoneration to be void. I
further agree to furnish proof, when required, relative to any portion of this information. The Board of School
Directors reserves the right to request a copy of your federal income tax return in support of this application.
______________________________________________
_____________________________________
Signature
Date
This application, supporting documentation and per capita bill are to be returned to:
Berkheimer Tax Administrator, PO Box 25144, Lehigh Valley, PA 18002-5144
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