Philadelphia Wage Tax Refund Petition Form – Fill Out and Use This PDF

			PETITION NUMBER (Office use only)
CITY OF PHILADELPHIA	DEPARTMENT OF REVENUE
REFUND PETITION
		FUND	SOURCE	INDEX

For all refunds except Individual Employee Wage Tax

SEE INSTRUCTIONS ON REVERSE. CLEARLY PRINT OR TYPE ALL INFORMATION.

1. PETITIONER'S NAME (First Name, Middle Initial, Last Name)

6. PROPERTY ADDRESS (For Real Estate, Water, Commercial Waste and Business Use & Occupancy Refunds only)

8.REFUND TYPE (Check all that apply and list below. For Wage Tax, Real Estate Tax and Other, see important information on reverse.)

Wage Tax

Business Income & Receipts Tax *

Net Profits Tax

Business Use & Occupancy Tax

Parking Tax

Amusement Tax

Water/Sewer

Liquor Tax

Hotel Tax

Commercial Waste

School Income Tax

Licenses and Permits

Tobacco Tax

Earnings Tax

Police Services

Departmental Payments

Real Estate Tax

Other (specify)______________________________________

* Business Income & Receipts Tax prior to 2012

was known as Business Privilege Tax.

A. TAX ACCOUNT

B. TAX YEAR OR

C. AMOUNT OF

A. TAX ACCOUNT

B. TAX YEAR OR

C. AMOUNT OF

NUMBER

PERIOD/YEAR

CLAIM

NUMBER

PERIOD/YEAR

CLAIM

9. REASON FOR THIS REFUND PETITION

I HEREBY CERTIFY that the statements contained herein and in any supporting schedule or exhibit are true and correct to the best of my knowledge and belief. I understand that if I knowingly make any false statements herein, I am subject to penalties as prescribed by law.

PETITIONER'S SIGNATURE		DATE
AUTHORIZED SIGNATURE FOR OTHER DEPARTMENT	TITLE	DATE

	MAIL COMPLETED REFUND PETITION TO:	REFUND INFORMATION:
	OR FAX TO: 215-686-6228
		TELEPHONE: 215-686-6574, 6575, 6578
	CITY OF PHILADELPHIA
		FAX: 215-686-6228
	DEPARTMENT OF REVENUE
		E-MAIL: refund.unit@phila.gov
	P.O. BOX 1137
		INTERNET: www.phila.gov/revenue
	PHILADELPHIA, PA 19102-1137

83-A-15 (Rev 4-29-2013)

Instructions for Completing the Refund Petition

This form is to be used for all refund requests except Individual Employee Wage Tax. If you need to file an individual employee wage petition, refer to the contact information on the front of this form. Employers must use this petition for withheld wage tax refund requests.

1.Individuals - Enter the name of the petitioner.

2.Business Name - For non-individual petitioners, enter the name of the entity.

3.Mailing Address - Enter the address where the refund is to be mailed.

4 and 5. Social Security and Federal Employer Identification Numbers - Individuals must enter a Social

Security number. All other entities must enter a Federal Employer Identification Number.

6.Property Address - This is required for all Real Estate, Water/Sewer, Commercial Waste and Business Use & Occupancy petitions. Enter the address of the property for which the refund is being requested.

7.Contact Information - Provide a phone number, fax number and e-mail address where you can be reached.

8.Refund Type - Check the appropriate block(s). If the type is not listed on the front of this form, check "Other" and specify the type of refund requested. A single Refund Petition may be used for multiple tax types and years.

A.Tax Account Number - Enter the tax specific account number(s).

B.Tax Years and/or Tax Periods - If tax is an annual tax, enter year. If tax is periodic,

e.g., quarterly or monthly, enter period(s) and year(s).

C.Amount of Claim - Enter the amount of the refund requested.

9.Reason for Refund - Enter reason for refund. If you have additional documentation, attach to this petition.

Wage Tax - Additional information is required before a decision can be made on your refund request. Provide a letter on company letterhead (signed by an officer of the company) stating that the additional tax withheld has been returned to the employees. If your refund request is resulting from a duplicate payment, provide supporting documentation. If you have questions about your filing requirements, application of payments or tax balances, call Taxpayer Services at 215-686-6600.

Real Estate - Refund requests must be accompanied by a copy of the front and back of the canceled check(s). If the refund is due to a sale of the property or refinancing, you must also supply a copy of the settlement sheet. Mortgage companies must supply a copy of the disbursement/check listing.

This petition must be signed and dated! If you have any questions regarding the preparation of this petition, see the contact information on the front of this form.

OFFICE USE ONLY - Licenses and Permits; Interdepartmental Refunds and Other - All petitions must include the signature and title of the Department's authorized designee, along with the Fund, Source and Index Code of the payment in addition to the petitioner's signature.

83-A-15 Reverse (Rev. 4-29-2013)