Real Estate Tax Installment Plan Application - 2003 - City Of Philadelphia

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MAKE NO MARKS IN THIS AREA
City of Philadelphia
7 1 0 3
Filing Deadline: February 28, 2003
Year 2003
Real Estate Tax
Installment Plan Application
New Applicants Only
2002 Program Participants Do Not Need to File this Application
Re al Estate Tax Account Num be r
Prim ary Addre s s
-
-
Print Applicant's Nam e
Last:
First:
Applicant's Social Security Num be r
Payment Plan
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-
Low Incom e
(Choose up to 8 payments)
Applicant's Birth Date
-
-
Low Incom e Senior Citizen
(Choose up to 20 payments)
Print Spous e 's Nam e
Total Mem be rs of House hold
Last:
First:
(To determine eligibility,
Spous e 's Social Se curity Num be r
compare total income to
-
-
members of household
per chart on reverse.
Spous e 's Birth Date
-
-
Household Income
1. Total 2001 Gross Social Security And Supplemental Security Income
,
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(Medicare premiums must be included)............................................................................1.
2. Total 2001 Gross Pensions, Annuities, Veterans' & Railroad Retirement Retirement
,
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Benefits and taxable portion of Individual Retirement Accounts (IRAs)...........................2.
3. Total 2001 Salary, Wages, Bonuses, Commissions, Income from Self-Employment
,
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and Partnership Income (Do not subtract losses)...........................................................3.
,
. 0 0
4. Total 2001 Interest, Dividends, Capital Gains, Prizes (Do not subtract losses)................4.
5. Total 2001 Net Rental Income and Net Business Income (Do not include rent you
,
. 0 0
pay; do not subtract rental or business losses from your total income)..........................5.
6. Total 2001 Other Income (Cash Public Assistance, Unemployment and Workers'
,
. 0 0
Compensation, Alimony, Support Money, Gifts totaling more than $500, Life
Insurance Death Benefit Payments exceeding $10,000 per person)...............................6.
,
. 0 0
7. TOTAL (Add Lines 1 through 6) ANNUAL FIGURE.........................................................7.
Under penalties of perjury, as set forth in 18 Pa. C.S. §§ 4902-4903 as amended, I sw ear that I have review ed this return and
accompanying statements and schedules, and to the best of my know ledge and belief, they are true and complete.
Taxpayer Signature_______________________________________
Date________________ Phone #____________________
Preparer Signature________________________________________ Date________________ Phone #____________________
MAIL TO: PHILADELPHIA DEPARTMENT OF REVENUE
P.O. BOX 53190
PHILADELPHIA, PA 19105
QUESTIONS: (215) 686-6442
E-mail: revenue@phila.gov

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