Employer: 

Mail Completed Form To:
P.O. BOX 519
                                                   Per Capita Tax                                     KEYSTONE®
IRWIN PA 15642
                                                                                                      collections group
Fax: 1-412-927-3634                     Exemption Application

                                                   School District or Municipality

Name:                                                                                Tax Year 
Address:                                                                             SSN 
City/State/Zip:                                                                      Account Number 

                This universal Exemption Application may be used by any PA taxpayer whose community has adopted 
                one or more tax exemptions. Applicant may be required to furnish additional information (including a 
                copy of applicant’s Pennsylvania state income tax return) to clarify, verify or support this application.

Non-Resident
          Previous Address                                  Current Address

          Move in Date:                                                             Move in Date:  
                           mm dd  yyyy                                                            mm dd  yyyy 
          Move out Date:                                                            Move out Date:  
                           mm dd  yyyy                                                            mm dd  yyyy 
                Provide copy of lease, deed, or utility bill covering above dates

Age Exemption
          Date of Birth:  
                           mm dd  yyyy 
                         Provide copy of birth certificate or valid driver’s license
Deceased     
          Date of Death:  
                           mm dd  yyyy 
                           Provide copy of death certificate
Income Exemption
          Annual Income (from all sources):        $
          If an Income Exemption was adopted by your taxing jurisdiction, then you must meet the income requirements established by your community. 
          Include a copy of your 1040 Tax Form along with any W-2(s), 1099(s), Form SSA-1099, or other supporting documentation. Note: all sources of 
          income includes (but is not limited to): wages, salary, fees, commission, gross business income, retirement 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.

Other reason for seeking exemption
Check only if an exemption other than those listed 
above apply in your community. Include applicable 
supporting documentation.

                Information received by the Tax Collector is considered CONFIDENTIAL and for official 
                purposes relating to the collection, administration and enforcement of the tax. 

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