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Application for Delinquent Individual Earned Income Tax Exoneration
This form should be used if requesting an exoneration.
Taxpayer Information
Applicant's First Name
Applicant's Last Name
Mailing Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
Idaho
Illinois
Indiana
Iowa
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Maine
Maryland
Massachusetts
Michigan
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Nevada
New Hampshire
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North Carolina
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Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
–
American Samoa
Federated States of Micronesia
Guam
Marshall Islands
Northern Mariana Islands
Palau
Puerto Rico
Virgin Islands
Zip code
Email
Phone
Exemption Request Information
Account Number From Bill
The Account Number can be found to the right of the name and address on the bill and also in a box titled Account Number.
Tax Year Instructions
What is the Tax Year you are applying to be placed on the list of taxpayers exempted from payment of the Earned Income Tax for the year?
Tax Year
Reason Instructions
What is the Reason you are applying to be placed on the list of taxpayers exempted from payment of the Earned Income Tax?
Reason
Deceased. The taxpayer listed on the bill is deceased.
Duplicate Account. I have multiple account numbers for the tax and tax year.
Moved.
Other. Please specify the reason in the field below.
By completion of this application
Confirm & Agree
I hereby state that the above facts are true and correct, and that I understand I may be subject to the penalties contained in the Pennsylvania Crimes Code for un-sworn falsifications to legal authorities if any of the above statements are incorrect.
Submit
