Form 83-T-619 - Refund Petition

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CITY 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 Number
1. PETITIONER'S NAME (First Name, Middle Initial, Last Name)
(Office use only)
2. BUSINESS NAME
4. SOCIAL SECURITY NUMBER
-
-
5. FEDERAL EMPLOYER IDENTIFICATION NO.
3. MAILING ADDRESS
-
CITY
STATE
ZIP CODE
6. PROPERTY ADDRESS (For Real Estate, Water and Business Use & Occupancy Refunds Only)
7. PHONE NUMBER
FAX NUMBER
E-MAIL ADDRESS
8. REFUND TYPE (Check all that apply and list below.)
Wage Tax
Business Privilege Tax
Net Profits Tax
Business Use & Occupancy Tax
Parking Tax
Liquor Tax
Water/Sewer
Real Estate Tax
Hotel Tax
Amusement Tax
School Income Tax
Other (specify)________________
A. TAX ACCOUNT
B. TAX YEAR OR
C. AMOUNT OF
A. TAX ACCOUNT
B. TAX YEAR OR
C. AMOUNT OF
NUMBER
PERIOD/YEAR
CLAIM
NUMBER
PERIOD/YEAR
CLAIM
9. REASON 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.
PETITIONER'S SIGNATURE
DATE
MAIL COMPLETED REFUND PETITION TO:
REFUND INFORMATION:
PHILADELPHIA DEPARTMENT OF REVENUE
PHONE: 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-T-619 (Rev. 11-29-2001)

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