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.

What is the Tax Year you are applying to be placed on the list of taxpayers exempted from payment of the per capita and/or occupation tax for the year.

What is the Reason you are applying to be placed on the list of taxpayers exempted from payment of the per capita and/or occupation tax?

Please tell us the date the taxpayer deceased.
Please list the other account number(s).
Please tell us the date the taxpayer moved out of the jurisdiction and the address they moved to.
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.