Form 83-A272 - Wage Tax Refund Petition Commission Employees

WAGE TAX REFUND PETITION

CITY OF PHILADELPHIA

DEPARTMENT OF REV ENUE

YEAR

REFUND UNIT

COMMISSION EMPLOYEES

2006

1401 JOHN F. KE NNEDY BOULEV ARD - ROOM 580

(Not to be used by Salaried Employees)

PHILADELPHIA, PA 19102

EMPLOYEE'S NAME (PLEA SE PRINT)

SOCIAL SE CURITY NUMBER

OFFICE USE ONLY

HOME ADDRESS

EMPLOYER IDENTIFICATIO N NUMBER (EIN)

DAYTIME TELEPHONE NUMBER

CITY

STATE

ZIP CODE

IF PA RTIAL Y EAR:

From__________ _______ To_____ ________ ____

EMPLOYER

OCCUPATION

PLACE OF E MPLOYMENT

SEE INSTRUCTIONS ON REVERSE SIDE OF THIS FORM

.00

1. GROSS COMPENSATION

2. COMPUTATION OF TAXABLE COMPENSATION AND/OR ALLOWABLE EXPENSES

.00

A. TOTAL SALES

.00

B. SALES OUTSIDE OF PHILADELPHIA

C. PERCENTAGE OF SALES OUTSIDE OF PHILADELPHIA (LINE 2B DIVIDED BY LINE 2A)

.00

D. COMMISSIONS EARNED OUTSIDE OF PHILADELPHIA (LINE 1 X LINE 2C)

E. NON -REIMBURSABLE BUSINESS EXPENSES, IF ANY (100% LESS LINE 2C X EXPENSES)

.00

SEE INSTRUCTIONS --ATTACH A COPY OF FEDERAL FORM #2106

.00

F. NON-TAXA BLE COMMISSIONS/ALLOWABLE EXPENSE (LINE 2D + LINE 2E)

.00

3. TAXABLE COMPENSATION (LINE 1 MINUS LINE 2F)

.00

RESIDENTS: LINE 3 X .04301

TAX DUE

NON-RESIDENTS: LINE 3 X .037716

.00

5. WAGE TAX WITHHELD PER W-2(S)

.00

6. REFUND REQUESTED (LINE 5 MINUS LINE 4)

EMPLOYER CERTIFICATION

I certify that the facts shown ab ove supporting employee's claims are correct based on available payroll records. Individuals serving as authorized

official signatories should be familiar with employee's time and attendance, as well as applicable Wage Tax Regulations. Income Tax Regulations

Section 401 through 404 requires that the employer properly withhold and allocate wages for tax purposes. General Regulation Section 306 (2)

provides that the employer, for and on behalf of the employee, requests the refund.

AUTHORIZED OFFICIAL SI GNATURE

PRINTED NAME

DAYTIME TELEPHONE NUMBER

EMPLOYEE CERTIFICATION

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 such penalties as may be prescribed by City Ordinance.

DAYTIME TELEPHONE NUMBER

TAXPAYER SI GNATURE

DATE

There are further directions for both the Employer as well as the Employee on the other side of

this form. Please read them before completing this document. Completed petition must include:

W-2 showing Federal, State, Medicare and Local wages

Signature of Employee and Employer

IRS form 2106 if claiming expenses (including breakdown of line 4)

83-A272 Rev. 8/26/2006

Form 83-A272 - Wage Tax Refund Petition Commission Employees - 2006

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