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City of Philadelphia

Return by:

8 1 1 2

Department of Revenue

October 14, 2011

2012 APPLICATION FOR SENIOR CITIZEN LOW INCOME SPECIAL REAL ESTATE TAX PROVISIONS

New Applicants Only. Prior Program Participants Do Not Need to File this Application.

Print Property Address (Must be Primary Residence.)

Real Estate Tax Account Number

Print Owner's Name

Owner's Social Security Number

Owner's Birth Date

Filing Status:

Single

Married

Print Spouse's Name

Spouse's Social Security Number

If qualifying spouse is deceased, enter the date of death:

Spouse's Birth Date

Household Income To qualify, total income must be $23,500 or less for a single person or $31,500 or less for a married couple.

1. Total 2010 Gross Social Security and Supplemental Security Income

. 0 0

(Medicare premiums must be included)...........................................................................1.

2. Total 2010 Gross Pensions, Annuities, Veterans' & Railroad Retirement Benefits,

. 0 0

and taxable portion of Individual Retirement Accounts (IRAs).........................................2.

3. Total 2010 Salary, Wages, Bonuses, Commissions, Income from Self-Employment

. 0 0

and Partnership Income (Do not subtract losses)...........................................................3.

. 0 0

4. Total 2010 Interest, Dividends, Capital Gains, Prizes (Do not subtract losses)..............4.

5. Total 2010 Net Rental Income and Net Business Income (Do not include rent

. 0 0

you pay; do not subtract rental or business losses from your total income)....................5.

6. Total 2010 Other Income (Cash Public Assistance, Unemployment and Workers'

Compensation, Alimony, Support Money, Gifts totaling more than $500,

. 0 0

Life Insurance Death Benefit Payments exceeding $10,000 per person)........................6.

. 0 0

7. TOTAL ANNUAL FIGURE (Add Lines 1 through 6).......................................................7.

Reminder: To qualify, total income must be $23,500 or less for a single person or $31,500 or less for a married couple.

Under penalties of perjury, as set forth in 18 PA C.S. §§ 4902-4903 as amended, I swear that I have reviewed this return and accompanying

statements and schedules, and to the best of my knowledge and belief, they are true and complete.

Taxpayer Signature________________________________________ Date_______________________Phone #_________________________

Preparer Signature________________________________________ Date_______________________Phone #_________________________

DO NOT SEND PHOTOCOPIES!

Rev. 7-18-2011 Final

Application For Senior Citizen Low Income Special Real Estate Tax Provisions - City Of Philadelphia - 2012

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