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Form WTEX - NON-RESIDENT EXEMPTION CERTIFICATE

CLAIM FOR EXEMPTION FROM CITY OF PITTSBURGH AND/OR SCHOOL DISTRICT EARNED INCOME TAX

FOR FULL-YEAR OR PART-YEAR PENNSYLVANIA RESIDENTS ONLY

COMPLETE THIS FORM IF YOUR RESIDENCY STATUS IS ONE OF THE FOLLOWING:

2 - Full-Year Mt. Oliver Resident

4 – Part-Year Resident of Pittsburgh

5 - Non-Resident of Pittsburgh

residing within the State of PA

during all or part of 2010

If you lived in another state during any part of the year, include copies of your PA and out of state returns.

Taxpayer Name___________________________________Social Security No.___________________Daytime Phone________________

Current

Address__________________________________________City______________________State_________Zip_________________

I was a resident of (Boro or Township)_______________________________________________________for all or part of year 2010.

I lived in the above municipality from ___________/____________/_____________ to __________/______________/_______________

As a resident of this municipality I earned $_______________________and I owe/paid $_______________________in earned income tax.

Therefore I was not liable for City of Pittsburgh and/or School District of Pittsburgh Earned Income Tax.

MUST BE VERIFIED AND SIGNED BY YOUR LOCAL TAX COLLECTOR FROM A PENNSYLVANIA MUNICIPALITY

I certify that the person above was registered as a taxpayer in my jurisdiction for the tax year 2010 and owes or has paid the

Earned Income Tax to his/her place of residence in the amount stated above.

____________________________________________________________

SEAL

Tax Collector’s Signature

Date

Phone

A completed PGH-40 must accompany all WTEX Forms

The balance of tax due on Form PGH-40 must be paid in full by the filing date by check. DO NOT SEND CASH. Make check payable to

“TREASURER, CITY OF PITTSBURGH” and mail it with your return. Please write your Account Number (found in the upper left corner of the

Taxpayer Information Box on Form PGH-40) or Social Security Number on your check.

DO NOT STAPLE ANY PAPERS TO THE RETURN

IF ALL APPLICABLE INFORMATION IS NOT PROVIDED, YOUR PGH-40 WILL BE RETURNED

Please mail your completed PGH-40 Income Tax Return in the envelope provided using

the correct color-coded label to the address indicated below.

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ATTENTION - REFUND

ATTENTION - CREDIT

ATTENTION – NO TAX DUE

TREASURER – CITY OF PITTSBURGH

414 GRANT ST

PO BOX 2701

PITTSBURGH PA 15219-2476

PITTSBURGH PA 15230-2701

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ATTENTION – PARTIAL or NO PAYMENT

ATTENTION – FULL PAYMENT

Returns sent to the incorrect address will

TREASURER – CITY OF PITTSBURGH

be delayed

414 GRANT ST

PO BOX 642583

PITTSBURGH PA 15219-2476

PITTSBURGH PA 15264-2583

Form Pgh-40 - Individual Earned Income - City And School District Of Pittsburgh - 2010 Page 2

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