Refund Petition Form (Page 2 of 2) in pdf

Instructions for Completing the Refund Petition

This form is to be used for all refund requests except Individual Employee Wage Tax. If you need to

file an individual employee wage petition, refer to the contact information on the front of this form.

Employers must use this petition for withheld wage tax refund requests.

1. Individuals - Enter the name of the petitioner.

2. Business Name - For non-individual petitioners, enter the name of the entity.

3. Mailing Address - Enter the address where the refund is to be mailed.

4 and 5. Social Security and Federal Employer Identification Numbers - Individuals must enter a Social

Security number. All other entities must enter a Federal Employer Identification Number.

6. Property Address - This is required for all Real Estate, Water/Sewer, Commercial Waste and Business

Use & Occupancy petitions. Enter the address of the property for which the refund is being requested.

7. Contact Information - Provide a phone number, fax number and e-mail address where you can be reached.

8. Refund Type - Check the appropriate block(s). If the type is not listed on the front of this form, check "Other"

and specify the type of refund requested. A single Refund Petition may be used for multiple tax types and years.

A. Tax Account Number - Enter the tax specific account number(s).

B. Tax Years and/or Tax Periods - If tax is an annual tax, enter year. If tax is periodic,

e.g., quarterly or monthly, enter period(s) and year(s).

C. Amount of Claim - Enter the amount of the refund requested.

9. Reason for Refund - Enter reason for refund. If you have additional documentation, attach to this petition.

Wage Tax - Additional information is required before a decision can be made on your refund request.

Provide a letter on company letterhead (signed by an officer of the company) stating that the

additional tax withheld has been returned to the employees. If your refund request is resulting from

a duplicate payment, provide supporting documentation. If you have questions about your filing

requirements, application of payments or tax balances, call Taxpayer Services at 215-686-6600.

Real Estate - Refund requests must be accompanied by a copy of the front and back of the canceled

check(s). If the refund is due to a sale of the property or refinancing, you must also supply a copy of

the settlement sheet. Mortgage companies must supply a copy of the disbursement/check listing.

This petition must be signed and dated! If you have any questions

regarding the preparation of this petition, see the contact information on

the front of this form.

OFFICE USE ONLY - Licenses and Permits; Interdepartmental Refunds and Other - All petitions must

include the signature and title of the Department's authorized designee, along with the Fund, Source

and Index Code of the payment in addition to the petitioner's signature.

83-A-15 Reverse (Rev. 11-6-2013)

Refund Petition Form Page 2