2024 PCT Exoneration Form – City of Butler

Per Capita Exoneration – Spring 2024

RETURN WITH TAX NOTICE TO:

BERKHEIMER TAX INNOVATIONS

PO BOX 25144

LEHIGH VALLEY PA 18002-5144

DUE DATE: APRIL 30, 2024

CITY OF BUTLER PER CAPITA EXONERATION FORM

SPRING TAX NOTICE 2024

PLEASE NOTE: An exoneration request and/or approval apply only to the current period.

A new form must be submitted for each year and each tax period.

*** IF YOU EARNED OR RECEIVED $10,000.00 OR MORE DURING 2023 YOU DO NOT QUALIFY FOR EXEMPTION:

Name*

Full Name

Date

Address

Street Address City State ZIP Code

Phone

ARE YOU EMPLOYED?

Yes

ARE YOU RECEIVING SOCIAL SECURITY/DISABILITY/PENSION OR ANY OTHER INCOME?

Yes

IF YES, LIST MONTHLY AMOUNT $

TOTAL YEARLY INCOME FROM ALL SOURCES: $

In addition to income requirements, you must also satisfy at least ONE of the following:

REASON FOR EXONERATION REQUEST (PLEASE CHECK ALL THAT APPLY)

65 YEARS OF AGE OR OLDER

PLEASE LIST DATE OF BIRTH

REASON FOR EXONERATION REQUEST (PLEASE CHECK ALL THAT APPLY)

LIVING IN A NURSING HOME

WIDOW OR WIDOWER (OVER 50 YEARS OF AGE)

ACTIVE MILITARY

FULL TIME STUDENT

SCHOOL YOUR ATTENDING

MENTALLY HANDICAPPED

PHYSICALLY DISABLED AND UNABLE TO WORK (LIST DISABILITY BELOW)

DESCRIPTION OF HANDICAP OR DISABILITY (IF APPLICABLE)

THE CITY OF BUTLER RESERVES THE RIGHT TO INDEPENDENTLY VERIFY ALL STATEMENTS MADE HEREIN:

I hereby declare that all statements made in the request are true and correct to the best of my knowledge.

SIGNATURE OF APPLICANT:*

APPROVED

DISAPPROVED

SIGNATURE*

Date*