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WTEX – COMPLETE THIS FORM FOR:

2-Mt. Oliver Resident

4-Part Year Resident (if another state, attach state tax form)

5-Non-Resident of Pittsburgh

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

FOR PENNSYLVANIA RESIDENTS ONLY

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__________________________________________City______________________State_________Zip_________________

I was a resident of (City, Borough or Township)_______________________________________________________for all or part of year 2001.

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 2001 and has paid the Earned

Income Tax to his/her place of residence for the amount stated above.

____________________________________________________________

SEAL

Tax Collector’s Signature

Date

Phone

GUIDELINES FOR COMPLETING LINE 2 – Include Federal Form 2106

Unreimbursed transportation and expenses, while away from home overnight (lodging, food, etc.), incurred as a condition of employment and

required by the employer are allowed as a deduction from gross income when computing the tax.

However, certain expenses allowable on the Federal Income Tax Return, which are claimed on Form 2106, are not allowable on the PGH-40.

The following are some examples of expenses that are not deductible.

Union Dues

Travel to and from work

Office in home

Work clothes, uniforms

Travel to a second job

Educational expenses

Protective clothing

License fees

Books, publications

Tools, supplies

Telephone expenses

Seminars, conferences

Travel in connection with education activity

Computer

Professional dues and subscriptions

Business expenses of an outside salesperson are deductible.

Non-Residents of Pennsylvania, who work in the City of Pittsburgh, may deduct only those expenses directly related to the performance of

their job in Pittsburgh.

Specify your occupation and briefly describe the circumstances in which expenses were incurred: ____________________________________

IF ALL APPLICABLE INFORMATION IS NOT PROVIDED, YOUR PGH-40 WILL BE RETURNED.

SEND COMPLETED TAX RETURN TO: TREASURER, CITY OF PITTSBURGH

NO TAX DUE-NO REFUND

PO BOX 642568

PITTSBURGH PA 15264-2568

REFUND REQUESTED

414 GRANT ST

PITTSBURGH PA 15219-2476

TAX DUE WITH FULL PAYMENT

PO BOX 642583

PITTSBURGH PA 15264-2583

TAX DUE WITH PARTIAL OR NO PAYMENT PO BOX 642583

PITTSBURGH PA 15264-2583

CREDIT REQUESTED

414 GRANT ST

PITTSBURGH PA 15219-2476

Form Pgh-40 - Individual Earned Income/form Wtex - Non-Resident Exemption Certificate - 2001 Page 2

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