Application For Per Capita and / or Occupation Exoneration Request Form | www.hab-inc.com

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This form should be used if requesting exoneration if an Exoneration Request form for the municipality and/or School District that you are being bill for is not available.

Check out our Exoneration Page to see if your municipality and / or School District has their own Exoneration Request Form.

Taxpayer Information

Applicants First Name *

Applicants Last Name *

Mailing Address *

Country

City

State

Zip code

Email *

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.

The date deceased.

Please attach supporting documentation (ie: death certificate)

Duplicate Account Number

Please list the other account number(s).

Moved

If you moved out of the jurisdiction, please complete our Moved Out Exoneration Form.

Other - Please specify

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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