Form Em-3 - Emergency & Municipal Services Tax

EM-3 2005

EMERGENCY & MUNICIPAL

SERVICES TAX

CFD

PERSONAL RETURN – EMPLOYEE ONLY

CITY OF PITTSBURGH

Rev 12/04

FOR OFFICIAL USE ONLY

Amended Return ( )

Tax Return No Longer Needed ( )

CITY ID

SOCIAL SECURITY #

SIGNATURE______________________________________________

Due on or before February 28, 2005

TITLE ___________________________DATE___________________

PHONE __(__________)_____________________________________

PREPARER’S NAME_______________________________________

PREPARER’S PHONE__(_________)__________________________

I hereby certify, swear and aver that all statements herein are true and correct to the best of my

knowledge and belief, being duly apprised of my duty under the law to submit honest and

complete information or be subject to the penalties provided by law.

Make name/address corrections above

MAKE SURE YOUR SIGNATURE AND DATE APPEAR ABOVE

USE BLACK INK ONLY ON THIS FORM

EMERGENCY & MUNICIPAL SERVICES TAX IS $52.00 PER YEAR

EMERGENCY & MUNICIPAL SERVICES TAX $52.00

2. PENALTY AND INTEREST PER MONTH 1.5% TOTAL

(If applicable)

Penalty per month 0.5% (0.005) Interest per month 1% (0.01)

3. TOTAL PAYMENT – Add lines 1 & 2

Make check payable to: TREASURER, CITY OF PITTSBURGH – DO NOT SEND CASH

Mail to: CITY TREASURER EM-3 – PO BOX 642606 – PITTSBURGH PA 15264-2606

A $30.00 fee will be assessed for any check returned from the bank for any reason.

INSTRUCTIONS

If you were employed after January, the return is due the last day of the following month.

If you are employed within the City of Pittsburgh and your employer is NOT required or WILL NOT withhold

the Emergency & Municipal Services Tax, you are required to pay the tax yourself using this form. Failure

to file will result in the imposition of a penalty and interest charge.

Emergency & Municipal Services Tax is $52.00 per person, per year. Pennsylvania law limits total payment

by one person to a maximum of $52.00 per year regardless of the number of employers in a year. For

information call 412-255-2510.

IF THIS FORM IS NO LONGER NEEDED, PLEASE COMPLETE THE FOLLOWING

My employer had deducted the tax. Your employer is required to furnish you with an “EVIDENCE OF

DEDUCTION CERTIFICATE”, giving the employer’s name and City Account Number.

EMPLOYER_______________________________CITY ACCOUNT NUMBER_________________

ADDRESS________________________________PHONE (_____)__________________________

My occupation is performed outside the City limits in (Municipality)___________________________

Form Em-3 - Emergency & Municipal Services Tax - 2005

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