Refund Petition Form
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1
2PETITION NUMBER (Office use only)
CITY OF PHILADELPHIA
DEPARTMENT OF REVENUE
REFUND PETITION
FUND
SOURCE
INDEX
For all refunds except Individual Employee Wage Tax
SEE INSTRUCTIONS ON REVERSE. CLEARLY PRINT OR TYPE ALL INFORMATION.
1. PETITIONER'S NAME (First Name, Middle Initial, Last Name)
2. BUSINESS NAME
4. SOCIAL SECURITY NUMBER
3. MAILING ADDRESS
5. FEDERAL EMPLOYER IDENTIFICATION NO.
CITY
STATE
ZIP CODE
6. PROPERTY ADDRESS (For Real Estate, Water, Commercial Waste and Business Use & Occupancy Refunds only)
7. PHONE NUMBER
FAX NUMBER
E-MAIL ADDRESS
8. REFUND TYPE (Check all that apply and list below. For Wage Tax, Real Estate Tax and Other, see important information on reverse.)
Wage Tax
Net Profits Tax
Business Use & Occupancy Tax
Business Income & Receipts Tax *
Parking Tax
Amusement Tax
Water/Sewer
Liquor Tax
Hotel Tax
Commercial Waste
School Income Tax
Licenses and Permits
Tobacco Tax
Earnings Tax
Police Services
Departmental Payments
*
Business Income & Receipts Tax prior to 2012
Real Estate Tax
Other (specify)______________________________________
was known as Business Privilege Tax.
A. TAX ACCOUNT
B. TAX YEAR OR
C. AMOUNT OF
A. TAX ACCOUNT
B. TAX YEAR OR
C. AMOUNT OF
NUMBER
PERIOD/YEAR
CLAIM
NUMBER
PERIOD/YEAR
CLAIM
9. REASON FOR THIS REFUND PETITION
I HEREBY CERTIFY that the statements contained herein and in any supporting schedule or exhibit are true and correct to the best of my
knowledge and belief. I understand that if I knowingly make any false statements herein, I am subject to penalties as prescribed by law.
PETITIONER'S SIGNATURE
DATE
AUTHORIZED SIGNATURE FOR OTHER DEPARTMENT
TITLE
DATE
MAIL COMPLETED REFUND PETITION TO:
REFUND INFORMATION:
OR FAX TO: 215-686-6228
TELEPHONE: 215-686-6574, 6575, 6578
CITY OF PHILADELPHIA
FAX: 215-686-6228
DEPARTMENT OF REVENUE
E-MAIL: refund.unit@phila.gov
P.O. BOX 53360
INTERNET:
PHILADELPHIA, PA 19105
83-A-15 (Rev 11-6-2013)
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