Form 83-A272 - Wage Tax Refund Petition Commission Employees

WAGE TAX REFUND PETITION

CITY OF PHILADELPHIA

DEPARTMENT OF REVENUE

YEAR

REFUND UNIT

COMMISSION EMPLOYEES

2003

1401 JOHN F. KENNEDY BOULEVARD - ROOM 580

(Not to be used by Salaried Employees)

PHILADELPHIA, PA 19102

EMPLOYEE'S NAME (PLEASE PRINT)

SOCIAL SECURITY NUMBER

OFFICE USE ONLY

HOME ADDRESS

EMPLOYER IDENTIFICATION NUMBER (EIN)

DAYTIME TELEPHONE NUMBER

CITY

STATE

ZIP CODE

IF PARTIAL YEAR:

From_________________ To_________________

EMPLOYER

OCCUPATION

A. 1/1/2003 to 6/30/2003

B. 7/1/2003 to 12/31/2003

PLACE OF EMPLOYMENT

Resident Rate: 4.5% (.045)

Resident Rate: 4.4625% (.044625)

Non-Resident Rate:

SEE INSTRUCTIONS ON REVERSE SIDE OF THIS FORM

3.9127% (.039127)

3.88% (.038801)

1. GROSS COMPENSATION

.00

2. COMPUTATION OF TAXABLE COMPENSATION AND/OR ALLOWABLE EXPENSES

FOR EMPLOYEES PAID ON A COMMISSION BASIS

A. TOTAL SALES

B. SALES OUTSIDE OF PHILADELPHIA

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

LINE 2A)

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

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

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

F. NON -TAXABLE COMMISSIONS/ALLOWABLE EXPENSE (LINE2D + LINE 2E)

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

4. TAX DUE (LINE 3 X APPLICABLE RATE) SEE RATES ON BACK

5. TOTAL TAX DUE (LINE 4, COLUMN A + LINE 4, COLUMN B)

6. TAX WITHHELD PER W-2(S)

7. REFUND REQUESTED (LINE 6 MINUS LINE 5)

EMPLOYER CERTIFICATION

I certify that the facts shown above 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 Section306 (2) provides

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

AUTHORIZED OFFICIAL SIGNATURE

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.

TAXPAYER SIGNATURE

DATE

DAYTIME TELEPHONE NUMBER

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 and Local wages

Signature of Employee and Employer

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

For further information, you may reach the Revenue Department Refund Unit at:

215-686-6574, 6575 or 6578

Send e-mail to revenue@phila.gov

83-A272 Rev. 2/2004

Form 83-A272 - Wage Tax Refund Petition Commission Employees - 2003

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