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WTEX – COMPLETE THIS FORM FOR:

2-Mt. Oliver Resident

4-Part Year Resident (if another state, attach state tax form)

5-Non-Resident of Pittsburgh

THIS FORM IS NOT COMPLETE UNTIL SIGNED BY YOUR LOCAL TAX COLLECTOR

FOR PENNSYLVANIA RESIDENTS ONLY

NON-RESIDENT EXEMPTION CERTIFICATE

CLAIM FOR EXEMPTION FROM CITY OF PITTSBURGH AND/OR

SCHOOL DISTRICT EARNED INCOME TAX

Taxpayer Name________________________________________Social Security #___________________Daytime Phone________________

Current Address__________________________________________City______________________State_________Zip_________________

I was a resident of (Borough or Township)_______________________________________________________for all or part of year 2004.

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 2004 and owes or has paid the

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

____________________________________________________________

SEAL

Tax Collector’s Signature

Date

Phone

GUIDELINES FOR COMPLETING LINE 2 – Include Pennsylvania Schedule UE

The guidelines under Act 166 of 2002 which took effect in 2003 follows the State of PA for allowable employee expenses. Pittsburgh therefore

allows a deduction of “allowable employee business expenses” for which the taxpayer was not reimbursed. In order to be claimed as an

expense, the items must be ordinary, necessary, reasonable and actually incurred in performing the duties of the job and directly related to

present employment. The PA Schedule UE covers these expenses; one must be attached to claim allowable employee business expenses.

LINE 2 – DEDUCTIONS FOR UNREIMBURSED EMPLOYEE BUSINESS EXPENSES ARE PERMITTED AS FOLLOWS: business related

auto expenses; union dues; professional license fees; small tools required for employment; and uniforms or work clothing not suitable for

everyday use. Employee business expenses will not be processed as a deduction without documentation. Attach PA Schedule UE or Federal

Form 2106. Contributions to deferred income plans such as IRA’s, 401K’s, and Keoghs cannot be deducted from taxable income.

PERSONAL EXPENSES ARE NOT DEDUCTIBLE.

Unreimbursed transportation and employee business expenses, while away from home overnight (lodging, food, etc.), incurred as a condition

of employment and required by the employer are allowed as a deduction from gross income when computing the tax.

Non-Residents of Pennsylvania, who work in the City of Pittsburgh, may deduct only those expenses directly related to the performance of

their job in Pittsburgh.

Specify your occupation and briefly describe the circumstances in which expenses were incurred: ____________________________________

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

SEND COMPLETED TAX RETURN TO

REFUND REQUESTED

CREDIT REQUESTED

NO TAX DUE – NO REFUND

TREASURER CITY OF PITTSBURGH

414 GRANT ST

PO BOX 2701

PITTSBURGH PA 15219-2476

PITTSBURGH PA 15230-2701

TAX DUE WITH PARTIAL OR NO PAYMENT

TAX DUE WITH FULL PAYMENT

TREASURER CITY OF PITTSBURGH

414 GRANT ST

PO BOX 642583

PITTSBURGH PA 15219-2476

PITTSBURGH PA 15264-2583

Form Pgh-40 - Individual Earned Income/form Wtex - Non-Resident Exemption Certificate - 2004 Page 2

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