Form Wtex - Non-Resident Exemption Certificate printable pdf download

Form Wtex - Non-Resident Exemption Certificate

W T E X FORM

COMPLETE THIS FORM FOR:

Mt. Oliver Resident

Non-Resident of Pittsburgh

Part Year Resident,

if another state, attach state tax form

THIS FORM IS NOT COMPLETE UNTIL SIGNED BY YOUR LOCAL TAX COLLECTOR

NON-RESIDENT EXEMPTION CERTIFICATE

CLAIM FOR EXEMPTION FROM CITY OF PITTSBURGH

AND/OR

SCHOOL DISTRICT EARNED INCOME TAX

Taxpayer Name________________________________________Social Security #___________________Daytime Phone________________

Current Address____________________________________________________________________________________________________

I was a resident of (City, Borough or Township)___________________________________________________for all or part of year________.

I lived in the above municipality from ___________/____________/_______________ to ____________/______________/_______________

As a resident of this municipality I earned $_________________________and I paid $___________________________in earned income tax.

Therefore I was not liable for City of Pittsburgh and/or School District of Pittsburgh Earned Income Tax.

TO BE COMPLETED BY YOUR LOCAL TAX COLLECTOR

FROM A PENNSYLVANIA MUNICIPALITY

I certify that the person above was registered as a taxpayer in my jurisdiction for the tax

year __________ and has paid the Earned Income Tax to his/her place of residence for the

amount stated above.

___________________________________________________________

SEAL

Tax Collector’ s Signature

Date

Form Wtex - Non-Resident Exemption Certificate