Real Estate Tax Installment Plan Application - City Of Philadelphia

MAKE NO MARKS IN THIS AREA

City of Philadelphia

Filing Deadline: February 28, 2010

7 1 1 0

Year 2010

Real Estate Tax

NEW APPLICANTS ONLY

Installment Plan Application

2009 Program Participants Do Not Need to File this Application

Primary Address

Real Estate Tax Account Number

Print Applicant's Name

Payment Plan

Low Income

(Choose up to 8 payments)

Applicant's Social Security Number

Applicant's Birth Date

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

per chart on reverse.)

Household Income

1. Total 2008 Gross Social Security and Supplemental Security Income

. 0 0

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

2. Total 2008 Gross Pensions, Annuities, Veterans' & Railroad Retirement Benefits,

. 0 0

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

3. Total 2008 Salary, Wages, Bonuses, Commissions, Income from Self-Employment

. 0 0

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

. 0 0

4. Total 2008 Interest, Dividends, Capital Gains, Prizes (Do not subtract losses)..................................4.

5. Total 2008 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 2008 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.

. 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. 7-17-2009 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

Real Estate Tax Installment Plan Application - City Of Philadelphia - 2010

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