Application for Delinquent Individual Local Services Tax Exoneration Form

This form should be used if requesting an exoneration.

Taxpayer Information

Exemption Request Information

The Account Number can be found to the right of the name and address on the bill and also in a box titled Account Number.
Tax Year Instructions
What is the Tax Year you are applying to be placed on the list of taxpayers exempted from payment of the Local Services Tax for the year?
Reason Instructions
What is the Reason you are applying to be placed on the list of taxpayers exempted from payment of the Local Services Tax?
I hereby state that the above facts are true and correct, and that I understand I may be subject to the penalties contained in the Pennsylvania Crimes Code for un-sworn falsifications to legal authorities if any of the above statements are incorrect.