Per Capita Tax And Occupation Resident Tax Exemption Application Form
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1PLEASE PRINT
Berkheimer Tax Administrator
2015.02.20
50 N. Seventh St.
Bangor, PA 18013
PER CAPITA TAX AND OCCUPATION RESIDENT TAX
EXEMPTION APPLICATION
Resident of:
___ S Versailles Twp
___ White Oak Boro
___ Irwin Borough
___ North Huntingdon Twp
___ North Irwin Borough
Name ___________________________________________________ Social Security # ___________________ (Required)
Address ___________________________________________________________________________________________
Application Date ________________________ Age ___________ Date of Birth______________________
PLEASE CIRCLE ONE:
RETIRED
UNEMPLOYED
HOMEMAKER
STUDENT
OTHER
IF OTHER please explain: ____________________________
_____ Per Capita Taxes for the year _____
My total income from ALL sources (including Social Security, Pensions, Disability, Sick pay, Investment income, etc.) is less
than Five Thousand Dollars ($5,000) and I was 62 years of age or older before July 1 of the current tax year. I hereby make
application to the Norwin School District Tax collector for exemption from the Per Capita Tax.
Income Received:
Monthly _____ Yearly _____ (check one)
Pension and all Retirement Benefits/Accounts
$ ______________________
Social Security
$ ______________________
Disability Benefits
$ ______________________
Income from Investments (Capital gains, Interest & Dividends, etc.)
$ ______________________
Income from Employment (wages, salaries, tips, etc.)
$ ______________________
Other (self-employed, rental income, partnership income, etc.)
$ ______________________
TOTAL INCOME FROM ALL SOURCES
$ ______________________
_____ Occupation Resident Tax for the year __________
No Occupation ______
I have no occupation or my total income from my occupation is less than Five Thousand Dollars ($5,000). There is no age
requirement to apply for Occupation Resident Tax exemption. I hereby make application to the Norwin School District tax
collector for exemption from the Occupation Resident Tax.
Income Received:
Monthly _____ Yearly _____ (check one)
Income from Employment (wages, salaries, tips, etc.)
$ ______________________
Other (self-employment, rental income, partnership income, etc.)
$ ______________________
TOTAL INCOME FROM OCCUPATION(S) ONLY
$ ______________________
I hereby apply for exemption from payment of the tax or taxes indicated and swear that the information given
herein is true and correct.
I UNDERSTAND IF I BECOME GAINFULLY EMPLOYED, IT IS MY RESPONSIBILITY TO REPORT THIS
INFORMATION TO THE BERKHEIMER TAX ADMINISTRATOR OFFICE IMMEDIATELY.
Submit Application To:
Berkheimer Tax Administrator
PO Box 25144
Signature of Applicant
Lehigh Valley, PA 18002-5144
(Must be signed)
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