Petition For Waiver Of Interest And Penalty - City Of Philadelphia - Department Of Revenue

CITY OF PHILADELPHIA - DEPARTMENT OF REVENUE

PETITION FOR WAIVER OF INTEREST AND PENALTY

For waiver of interest over $15,000 or penalty over $35,000 call the Tax Review Board

at 215-686-5216 or download the form from

CLEARLY PRINT OR TYPE ALL INFORMATION.

PETITIONER'S NAME (First Name, Middle Initial, Last Name)

ACCOUNT NUMBER

BUSINESS NAME

SOCIAL SECURITY NUMBER

MAILING ADDRESS

FEDERAL EMPLOYER IDENTIFICATION NO.

CITY

STATE

ZIP CODE

PHONE NUMBER

FAX NUMBER

E-MAIL ADDRESS

LIST TYPE OF TAX OR CHARGE, THE PERIOD COVERED AND INDICATE THE AMOUNT OF INTEREST AND PENALTY PETITIONED FOR WAIVER.

TAX TYPE

PERIOD/YEAR

INTEREST

PENALTY

TOTAL

GRAND TOTALS

REASON FOR THIS PETITION (Be brief and concise. Do not use reverse; attach additional sheets if necessary.)

I HEREBY CERTIFY

that the statements contained herein and in any supporting schedule or exhibit are true and correct to the best of myknowledge and belief. I understand

that if I knowingly make any false statements herein, I am subject to penalties as prescribed by law. I agree that if I accept the Department's determination of the amount of

interest and/or penalty to be abated, to pay any remaining balance owed without further appeal to the Tax Review Board.

PETITIONER'S SIGNATURE

DATE

DEPARTMENT OF REVENUE USE ONLY

DEPARTMENT OF REVENUE USE ONLY

REVIEWED BY

DATE

TERMS

SUPERVISORY APPROVAL

DATE

MAIL COMPLETED PETITION TO:

DEPARTMENT OF REVENUE

CITY OF PHILADELPHIA

CONTACT INFORMATION:

DEPARTMENT OF REVENUE

PHONE: 215-686-6600

1401 JOHN F. KENNEDY BOULEVARD

E-MAIL: revenue@phila.gov

PHILADELPHIA, PA 19102

INTERNET:

OR FAX TO: 215-686-6635

(Rev 8-29-2011)