Request For Abatement Form - City Of Amherst Income Tax Department

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City of Amherst
Income Tax Department
480 Park Avenue
Amherst, OH
44001-2258
Phone (440) 988-4212
Fax (440) 988-3749
Richard S. Ramsey - Treasurer
REQUEST FOR ABATEMENT
To be considered, this form must be returned within thirty (30) days
Name: ____________________________________________________________ SS # ____________________
Spouse’s Name ____________________________________________________ SS # ____________________
Address:_______________________________________________________________ Apt No. _____________
Phone: (
) _____________________________
I/We request abatement of the penalty and/or interest for the tax year(s): ______________
Reason:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Signature (s) ____________________________
_____________________________
Date: _________________
*******************************************************************************
FOR OFFICE USE ONLY
Year
Tax
Penalty
Interest
Notes: ______________________________________________
_____ _____
_____
_____
______________________________________
_____ _____
_____
_____
______________________________________

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