Real Estate Tax Installment Plan Application - City Of Philadelphia - 2011

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MAKE NO MARKS IN THIS AREA
City of Philadelphia
Filing Deadline: February 28, 2011
7 1 1 1
Year 2011
Real Estate Tax
NEW APPLICANTS ONLY
Installment Plan Application
2010 Program Participants Do Not Need to File this Application
Primary Address
Real Estate Tax Account Number
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Print Applicant's Name
Payment Plan
Low Income
(Choose up to 8 payments)
Applicant's Social Security Number
Applicant's Birth Date
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Low Income Senior Citizen
(Choose up to 20 payments)
Print Spouse's Name
Total Members of Household
(To determine eligibility,
compare total income to
Spouse's Social Security Number
Spouse's Birth Date
members of household
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per chart on reverse.)
Household Income
1. Total 2009 Gross Social Security and Supplemental Security Income
,
. 0 0
(Medicare premiums must be included)...............................................................................................1.
2. Total 2009 Gross Pensions, Annuities, Veterans' & Railroad Retirement Benefits,
,
. 0 0
and taxable portion of Individual Retirement Accounts (IRAs).............................................................2.
3. Total 2009 Salary, Wages, Bonuses, Commissions, Income from Self-Employment
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. 0 0
and Partnership Income (Do not subtract losses)...............................................................................3.
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. 0 0
4. Total 2009 Interest, Dividends, Capital Gains, Prizes (Do not subtract losses)..................................4.
5. Total 2009 Net Rental Income and Net Business Income (Do not include rent you pay;
,
. 0 0
do not subtract rental or business losses from your total income).......................................................5.
6. Total 2009 Other Income (Cash Public Assistance, Unemployment and Workers'
Compensation, Alimony, Support Money, Gifts totaling more than $500, Life Insurance
,
. 0 0
Death Benefit Payments exceeding $10,000 per person)....................................................................6.
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. 0 0
7. TOTAL HOUSEHOLD INCOME (Add Lines 1 through 6)...................................................................7.
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 #_________________________
Rev. 8-24-2010 Final
MAIL TO: PHILADELPHIA DEPARTMENT OF REVENUE
P.O. BOX 53190
PHILADELPHIA, PA 19105
QUESTIONS: 215-686-6442 E-MAIL revenue@phila.gov
REVENUE DEPARTMENT USE ONLY
REASON FOR REJECTION
APPROVED
REJECTED
Incomplete or Invalid Application
Income
Off-site Mailing Address
Other

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