Voluntary Statement Of Financial Status In Support Of Request For Deferment Of Per Capita Tax Payment For Saucon Valley School District printable pdf download

BERKHEIMER TAX ADMINISTRATOR

PO Box 25175

Lehigh Valley, PA 18002-5175

(610) 599-3143

VOLUNTARY STATEMENT OF FINANCIAL STATUS

In support of

REQUEST FOR DEFERMENT OF PER CAPITA TAX PAYMENT FOR SAUCON VALLEY

SCHOOL DISTRICT

July 1, 2012 to June 30, 2013

Full Name ________________________________

Date _____________________________

Address ___________________________________

Telephone No. _____________________________

Present Occupation __________________________

Previous Occupation _____________________________

Present Employer ____________________________

Previous Employer _____________________________

Present Total Annual Income

$___________ is received from the following:

Wages:___________ Social Security Income: _________

Other: ________

List Other Income Sources: ________________________________________

Present Age:________

Marital Status ________

Number of Dependents _______

I request deferment of payment of my Per Capita taxes for the 2012-2013 school year.

Note: "Any single individual eighteen (18) years of age and older, with a total income from all sources of ten

thousand ($10,000) dollars or less, or a married couple with a total combined income from all sources of twenty

thousand ($20,000) dollars or less, be exonerated from the payment of the Per Capita Tax under Act 511 and

under School Code Section 679."

This application exonerates any person eighteen (18) years of age and older from the payment of Per Capita taxes for the

2011-2012 school year only. In order to be eligible for exoneration, an application must be completed every year.

Documentation must be attached to the application before board approval:

1. A copy of a prior year’s federal income tax return, or if a federal return was not required to be filed, copies of

social security, disability or other non-taxable income statements

2. A copy of proof of attendance or registration to college or school as a full time student for the current year.

I/We agree to notify the Berkheimer Tax Administrator in the event of any change in my/our financial status, making me/us

ineligible for tax deferment.

I/We declare under penalties of perjury, that the above statements are true and correct to the best of my/our information

and belief.

ACCT NO. ______________

Mr. Mrs. Ms. _____________________________________________________

*Signature

SS NO._____________________

_____________________________________________________

Please attach Per Capita Bill(s) to this form

*Signature

*If couple applies for exoneration, two (2) signatures will be required.

APPROVED _______________ NOT APPROVED ___________________

DATE ____________________________

IMPORTANT: FILL IN THIS FORM COMPLETELY

THIS FORM MUST BE RECEIVED BY THE BERKHEIMER TAX ADMINISTRATOR ON OR BEFORE

APRIL 1, 2013

Voluntary Statement Of Financial Status In Support Of Request For Deferment Of Per Capita Tax Payment For Saucon Valley School District

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