"Per Capita Tax Exemption Request Form - Lebanon County School Districts" - Pennsylvania

Per Capita Tax Exemption Request Form - Lebanon County School Districts is a legal document that was released by the Berkheimer Tax Administrator - a government authority operating within Pennsylvania.

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BERKHEIMER TAX INNOVATIONS
PO Box 25144
Lehigh Valley, PA 18002-5144
Phone: 610-599-3143
LEBANON COUNTY SCHOOL DISTRICTS
Per Capita Tax
Exemption Request Form
District: __________________________________
Name:
_______________________________________
Account: ____________________________
Address: _______________________________________
Date: _______________________________
_______________________________________
Tax Year: ___________________________
Under penalties of perjury, I hereby certify that the information provided below is true and correct.
____________________________________________
Signature of Applicant
_______________________________________________________________________________________________
Reason for Exemption Request:
_____ Individual with an income of $10,000.00 or less
_____ Individual 65 years of age or older by July 1 of the subject tax year
_____ Individual under the age of 18 as of July 1 of the subject tax year
_____ Individual residing in a skilled nursing care center
_____ Individual who moved out of of the District prior to July 1 of the subject tax year
_____ Individual deceased prior to July 1 of the subject tax year
_____ Individual who is active duty military personnel during the subject tax year
_____ Individual who is permanently disabled
_____ Individual who is a member of the clergy
_______________________________________________________________________________________________
Applicants may be required to furnish additional information to clarify, verify or add to this application.
Applicant may be requested to furnish a copy of his of her PA income tax return.
_______________________________________________________________________________________________
OFFICE USE ONLY:
Request received by: ________ (initial)
Date Received: ____________________
Exemption: GRANTED / REFUSED
Date: ____________________________
BERKHEIMER TAX INNOVATIONS
PO Box 25144
Lehigh Valley, PA 18002-5144
Phone: 610-599-3143
LEBANON COUNTY SCHOOL DISTRICTS
Per Capita Tax
Exemption Request Form
District: __________________________________
Name:
_______________________________________
Account: ____________________________
Address: _______________________________________
Date: _______________________________
_______________________________________
Tax Year: ___________________________
Under penalties of perjury, I hereby certify that the information provided below is true and correct.
____________________________________________
Signature of Applicant
_______________________________________________________________________________________________
Reason for Exemption Request:
_____ Individual with an income of $10,000.00 or less
_____ Individual 65 years of age or older by July 1 of the subject tax year
_____ Individual under the age of 18 as of July 1 of the subject tax year
_____ Individual residing in a skilled nursing care center
_____ Individual who moved out of of the District prior to July 1 of the subject tax year
_____ Individual deceased prior to July 1 of the subject tax year
_____ Individual who is active duty military personnel during the subject tax year
_____ Individual who is permanently disabled
_____ Individual who is a member of the clergy
_______________________________________________________________________________________________
Applicants may be required to furnish additional information to clarify, verify or add to this application.
Applicant may be requested to furnish a copy of his of her PA income tax return.
_______________________________________________________________________________________________
OFFICE USE ONLY:
Request received by: ________ (initial)
Date Received: ____________________
Exemption: GRANTED / REFUSED
Date: ____________________________