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

Exemption Request Information

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 list the other account number.

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

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.