Annual Application For The Exemption From Payment Form printable pdf download

ANNUAL APPLICATION FOR THE EXEMPTION FROM PAYMENT

of the

Allentown City Residence Tax and the Allentown School District Residence & Per Capita Tax

for individuals 65 years of age or older

TAX YEAR __________

INSTRUCTIONS:

Answer all questions fully and correctly. An entry must be made in each item. Show name and

address information as it appears on the tax bill.

(1)

Full Name of Claimant___________________________________________

Date of Birth________________

(2)

Mailing Address _____________________________________ Apt.#_________

Phone______________

City_______________________________State___________Zip Code______________________

(3)

Status:

Single______

Married______

(4)

Social Security #__________________

REPORT MONTHLY INCOME FROM: (INCOME MAY NOT EXCEED $5,000.00 PER YEAR FROM ALL SOURCES)

Social Security

$ _______________

(including disability benefits)

Pension

_______________

Royalties

_______________

Interest & Dividends

_______________

(exclude interest exempt from Federal/State Tax)

Net Rental Income

_______________

Employment

_______________

(gross income)

Workers’ Compensation

_______________

Unemployment Compensation

_______________

Alimony/Support

_______________

(paid either pursuant to Court Order, written agreement

or voluntary basis)

Other

_______________

(identify)

TOTAL

$ _______________

SUBMIT:

PROOF OF INCOME FROM EACH SOURCE OF INCOME. Acceptable proof includes copy of monthly

check(s) for Social Security, Pension, etc.; statement from Social Secuity, Pension Fund re: monthly income

due; check stub from employer or statement re: gross income; copy of Federal Income Tax Return for most

recent tax year filed.

VERIFICATION:

I, the undersigned, hereby certify that all information as herein stated is true and accurate for the

tax year stated, and do hereby swear or affirm that the statements made herein are true and correct

to the best of my knowledge. I understand this applies to the current tax year only.

DATE: _________________

SIGNATURE: ____________________________________________________

SUBMIT APPLICATION TO:

Berkheimer Tax Administrator

PO Box 25144

Lehigh Valley, PA 18002-5144

============================================================================================

TAX OFFICE USE ONLY:

City:

Approved________

Rejected________

School:

Approved________

Rejected________

By:_______________________________________

Date: _____________________________________

Reason for Rejection: ________________________

__________________________________________

============================================================================================

Enacted by Ordinance of City of Allentown and Resolution of School District of the City of Allentown - April 1985 - effective July 1, 1985 tax year.

Annual Application For The Exemption From Payment Form

Related Articles

Related forms

Related Categories