Mail Completed Form To:
   PO BOx 519
 IrwIn PA 15642           P  Cer                                    APItA tAx
Fax: 1-412-927-3634                                     xemPtIOn APPlICAtIOn
                                                        e

      This universal application form may be used by a PA taxpayer whose community has adopted one or more tax exemptions. 
Exemption from tax is applicable to the current tax year only. You must file exemption application each year you receive a tax bill.

                                                         School District or Municipality

Name                                                                     Account #
                                                                                            (as indicated on bill)

Address                                                                  Tax Year

                                                                         SSN

Phone                                                                    Occupation

        Moved
         Previous address                                                Current address

         Move-out date                                                   Move-in date
                        Provide copy of lease, deed or utility bill covering above dates

        Age Exemption                                               If your taxing authority adopted an age exemption, you must meet 
         Date of birth                                              the requirements established by your community. Provide copy of 
                                                                    birth certificate or valid driver’s license.

        Deceased
         Date of death                                              Provide copy of death certificate or obituary

        Income Exemption
         Annual income (from all sources)
        If your taxing authority adopted an income exemption, you must meet the requirements established by your community. Income from all 
        sources includes (but is not limited to): wages, salary, fees, commission, gross business income, pension, Social Security, TANF, child 
        support, alimony or separate maintenance payments, military pay, unemployment compensation, interest, rents, royalties, dividends, 
        annuities, income from estates or trusts. Provide documentation. For example: W-2; PA-40; Schedule(s) C, E, F, and/or RK-1. 

        Other reason for seeking exemption
        Check only if an exemption is included on your tax bill that is not listed on this form (write exemption from tax bill in the space above)

I declare under penalty of law that the information stated here and submitted with this form is true and correct. I understand and 
acknowledge that the information I provide with this application is subject to verification and audit at any time. 

                       Signature of Applicant                                           Date

Information received by the Tax Collector is considered CONFIDENTIAL and for official purposes relating to the collection, administration and enforcement of the tax. 
        Additional information may be required (including a copy of applicant’s state income tax return) to clarify, verify or support this application.