Form Pgh-40 - Individual Earned Income/form Wtex - Non-Resident Exemption Certificate - 2004

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PGH-40 2004
CFD
CITY AND SCHOOL DISTRICT
OF PITTSBURGH
Individual Earned Income for Calendar
Year and/or Fiscal Year Ended ______
Rev 09/04 For Offical Use Only
YOU MUST ENTER YOUR SOCIAL SECURITY NUMBER(S)
( ) Check if Amended Return
( ) Check if form is no longer needed
__________________________
___________________________
ACCT #
Social Security #
Spouse’s Social Security #
_____________________________ ______________________________
Last Name
First Name
_____________________________ ______________________________
Spouse’s Last Name
Spouse’s First Name
_____________________________________________________________
Address
City
State
Zip Code
_____________________________________________________________________
______________________
_________________________
SIGNATURE & PHONE OF PREPARER-
Other than taxpayer, based on all information
Occupation
Spouse’s Occupation
of which PREPARER has knowledge.
FILING
( ) Single
( ) Married filing Jointly – Both must sign
( ) Married filing Separately
( ) Deceased – Date of Death
STATUS
CHECK ONE
RESIDENCY
( ) 1-Resident
( ) 2-Mt. Oliver Resident
( ) 3-Non-Resident of PA
( ) 4-Part Year Resident of PGH ( ) 5-Non-Resident of PGH
STATUS
Full Year
Complete WTEX on back
Include VISA or Out of
Complete WTEX on back
Complete WTEX on back
CHECK ONE
See page –4-
____________State Return
_____/_____ to _____/_____
Municipality_______________
1.
EARNINGS - Gross wages, tips, salaries, commissions, etc.
Attach photocopy of W-2 forms, 1099 forms, etc.
Enclose Photo Copy of W-2(s)
•
1
2.
LESS UNREIMBURSED EMPLOYEE BUSINESS EXPENSES
Must include copies of PENNSYLVANIA SCHEDULE UE and specify occupation above.
•
2
3.
TAXABLE EARNINGS
Line 1 minus Line 2
•
3
4.
NET PROFIT - From business, profession, rental business, partnerships, etc.
Include copies of Schedules C, 1065, K-1.
Instructions page –8-
•
4
5.
TOTAL GROSS COMPENSATION/NET PROFIT
Line 3 plus Line 4
If a negative number, enter 0
•
5
6.
TAX – Multiply Line 5 by the tax rate; DO NOT ROUND TO THE NEAREST DOLLAR
City Resident 3.0% (0.03) – Mt. Oliver Resident 2.0% (0.02) – Non-Resident of PA 1% (0.01)
•
6
7.
TOTAL LOCAL TAX WITHHELD PER W-2(s)
Enclose Photo Copy of W-2(s)
•
7
8.
TOTAL ESTIMATED TAX PAYMENTS ON NP-5
UNDER S.S.# ___________ - ________ - ___________
•
8
9.
TOTAL PAYMENTS ON WT-4
UNDER S.S.# ___________ - ________ - ___________
•
9
10. OTHER CREDITS
Include Schedule – See page –9-
•
10
11. TOTAL TAX CREDITS
Add Lines 7, 8, 9 and 10
•
11
12. IF LINE 11 IS MORE THAN LINE 6 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -ENTER AMOUNT OVERPAID
Amounts of $2.00 or less are not refundable or credited.
CHECK ONE - REFUND ( )
CREDIT NEXT YEAR ( )
•
12
13. IF LINE 6 IS MORE THAN LINE 11 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ENTER AMOUNT OWED
Amounts of $2.00 or less are not due.
•
13
14. PENALTY AND INTEREST
•
If filed after APRIL 15, 2005, 1% per month of LINE 13 – see page –9-
14
15. TOTAL Add Line 13 and Line 14 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - TOTAL AMOUNT REMITTED
Make check payable to: TREASURER, CITY OF PITTSBURGH – DO NOT SEND CASH
•
A $30.00 service fee will be charged for any check returned from the bank for any reason.
15
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements. To the best of my knowledge and belief it is true, correct, and complete.
______________________________________________________________________
_______________________________________________________________________
SIGNATURE
DATE
DAYTIME PHONE
SPOUSE’S SIGNATURE – IF FILING JOINTLY, BOTH MUST SIGN

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