Hardship Application - Berks County printable pdf download

APPLICATION FOR HARDSHIP AGREEMENT

OWNER NAME:_____________________________________________________________

PROPERTY ADDRESS:______________________________________________________

TAX PARCEL#____________________

TAX CLAIM ACCOUNT#_________________

OWNER PHONE NUMBER________________

DO YOU OWN THE PROPERTY LISTED ABOVE?

(Circle one)

Yes

DO YOU LIVE IN THE PROPERTY LISTED ABOVE?

(Circle one)

Yes

PLEASE SELECT ONE (1) OF THE FOLLOWING TWO (2) EXTENUATING CIRCUMSTANCES

TO BE ACCEPTED INTO A HARDSHIP AGREEMENT TO STAY THE TAX SALE OF YOUR

PROPERTY

SERIOUS PHYSICAL ILLNESS OR INJURY OR COMBINATION OF THE ILLNESS OR

INJURY WITH A STATE OF PROLONGED UNEMPLYMENT

(a) Are you a permanent resident of the Commonwealth of Pennsylvania/?

Yes

(b) Has the illness or injury, or combination thereof, occurred or persisted

Yes

during any of the tax years for which the delinquent taxes were assessed or

during the year immediately preceding any such delinquency?

Yes

of the owner’s failure to pay any such delinquent tax or taxes to the date of this

application

(d) Please complete the Authorization for Disclosure of Healthcare Information

and have your health care provider (physician) complete the Physician’s

Attending Certification. Your Application will not be processed until

receipt of both forms.

PROLONGED UNEMPLOYMENT

(a) Are you a permanent resident of the Commonwealth of Pennsylvania/?

Yes

(b) Has your unemployment occurred or was persistent during any of the

Yes

tax years for which the delinquent taxes were assessed or during the year

immediately preceding any such delinquency?

Yes

your delinquent taxes?

(d) Please provide a copy of your Notice of Financial Determination

(Form UC-44F) from the Pennsylvania Department of Labor & Industry

Your application will not be processed until receipt of this form.

I, ___________________________________ verify that the facts set forth in the foregoing are true and

correct, to the best of my knowledge, information, and belief. I understand that the statements contained

herein are made subject to the penalties of 18 PA C.S.A. Section 4904 relating to unsworn falsification to

authorities.

____________________________________________

___________________

(Owner’s signature)

(Date)

PLEASE RETURN THIS COMPLETED APPLICATION AND REQUIRED FORMS TO: BERKS COUNTY

TAX CLAIM, HARDSHIP PROGRAM, 633 COURT STREET,2

FL, READING, PA 19601

TELEPHONE (610-478-6625)

FOR OFFICE USE ONLY __ ACCEPTED __ DENIED

Hardship Application - Berks County

Related Articles

Related forms

Related Categories