Form 83-A-7 - Wage Tax Refund Petiti X Refund Petition (1999) - Philadelphia
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1YEAR
•
CITY OF PHILADELPHIA
DEPARTMENT OF REVENUE
W
W
W A A A A A G G G G G E T
E T
E T
E TA A A A A X REFUND PETITI
X REFUND PETITI
X REFUND PETITI
X REFUND PETITIO O O O O N N N N N
W
W
E T
X REFUND PETITI
REFUND
UNIT
199
199 9 9 9 9 9
199
199
199
1401 J
F. K
B
- R
580
OHN
ENNEDY
OULEVARD
OOM
C
W-2 M
B
A
OMPLETE
UST
E
TTACHED
P
, PA
19102
HILADELPHIA
EMPLOYEE'S NAME (PLEASE PRINT)
SOCIAL SECURITY NUMBER
HOME ADDRESS
DAYTIME TELEPHONE NUMBER
CITY
STATE
ZIP CODE
IF PARTIAL YEAR:
From ______________ To ________________
EMPLOYER
EMPLOYER IDENTIFICATION NUMBER (EIN)
A. 1/1/99—6/30/99
PLACE OF EMPLOYMENT
B. 7/1/99—12/31/99
Resident Rate: 4.6869% (.046869)
Resident Rate: 4.6135% (.046135)
Non-Resident Rate:
Non-Resident Rate:
4.075% (.04075)
4.0112% (.040112)
SEE INSTRUCTIONS ON REVERSE SIDE OF THIS FORM
1. GROSS WAGES, ETC.
.00
.00
2. COMPUTATION OF ALLOWABLE EARNINGS AND/OR EXPENSES FOR EMPLOYEES
PAID ON A STRAIGHT SALARY BASIS
A. NUMBER OF DAYS /HOURS
182 Days
183 Days
B. NUMBER OF NON—WORKDAYS/HOURS (WEEKEND + VACATION + HOLIDAY
+ LEAVE + SICK = NON—WORKDAYS/HOURS)
Days/Hours
Days/Hours
C. NET NUMBER OF WORKDAYS/HOURS (LINE 2A MINUS 2B)
Days/Hours
Days/Hours
D. NUMBER OF DAYS/HOURS WORKED OUTSIDE PHILADELPHIA IN LINE 2C
Days/Hours
Days/Hours
E. PERCENTAGE OF TIME WORKED OUTSIDE PHILADELPHIA (LINE 2D DIVIDED BY 2C)
%
%
F. COMPENSATION EARNED OUTSIDE PHILADELPHIA (LINE 1 x LINE 2E)
G. NON—REIMBURSABLE BUSINESS EXPENSES, IF ANY (100% MINUS LINE 2E x
EXPENSES) (SEE INSTRUCTIONS — ATTACH COPY OF FEDERAL FORM #2106)
H. EXEMPT INCOME (LINE 2F + LINE 2G)
3. COMPUTATION OF ALLOWABLE COMPENSATION AND/OR EXPENSES FOR EMPLOYEES
PAID ON A COMMISSION BASIS
A. TOTAL SALES
B. TOTAL SALES OUTSIDE OF PHILADELPHIA
C. PERCENTAGE OF SALES OUTSIDE OF PHILADELPHIA (LINE 3B DIVIDED BY LINE 3A)
%
%
D. SHARE OF COMMISSIONS EARNED OUTSIDE OF PHILADELPHIA (LINE 1 x LINE 3C)
E. NON-REIMBURSABLE BUSINESS EXPENSES, IF ANY (100% MINUS LINE 3C x EXPENSES)
(SEE INSTRUCTIONS - ATTACH COPY OF FEDERAL FORM #2106)
F. EXEMPT COMMISSIONS (LINE 3D + LINE 3E)
4. TAXABLE COMPENSATION (LINE 1 MINUS LINE 2H AND/OR LINE 3F)
5. TAX DUE (LINE 4 x APPLICABLE RATE) (SEE RATES ON BACK)
6. TOTAL TAX DUE (LINE 5, COLUMN A + LINE 5, COLUMN B)
7. TAX WITHHELD PER W-2(S)/TAX PREVIOUSLY PAID
8. REFUND (LINE 7 MINUS LINE 6). FEDERAL LAW REQUIRES THE CITY TO REPORT THIS
AMOUNT, THE EMPLOYEE'S NAME, ADDRESS AND SOCIAL SECURITY NUMBER TO
THE INTERNAL REVENUE SERVICE.
CERTIFICATION BY EMPLOYER:
I certify that the facts shown above supporting employee's claims are correct based on available payroll records.
AUTHORIZED OFFICIAL SIGNATURE
PRINTED NAME
DAYTIME TELEPHONE NUMBER
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 state or ordinance.
TAXPAYER SIGNATURE
DATE
DAYTIME TELEPHONE NUMBER
83-A-7 (Rev. 11/99)
(over)
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