Application For Per Capita and / or Occupation Exoneration

Before applying for an exoneration, CLICK HERE to see if your locality has a special form.

Taxpayer Information

Applicant's First Name

Applicant's Last Name

Mailing Address

City

State

ZIP Code

Phone

Exemption Request Information

Account Number From Bill

Bill Number From Bill

Tax Year Instructions

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.

Tax Year

Reason Instructions

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?

Reason

Deceased. The taxpayer listed on the bill is deceased. Duplicate Account. I have multiple account numbers for the tax and tax year. Other. Please specify the reason in the field below.

Date deceased / Duplicate Account Number / Other (Please specify)

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By completion of this application,

Confirm & Agree

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.

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