3. City ID Number
4. FEIN
9. Email Address
8. Phone Number
1. Taxpayer's Name (First, Last)
REQUEST FOR PENALTY WAIVER
Business Tax Only
5. Social Security Number
D. Amount of
Requested Penalty
6. Business Address (Street, City, State, Zip)
Date of Request
General Information
Use this form to request an abatement of penalty in a given tax period for a particular tax type.
Taxpayer must show either:
1. That the failure to make a timely payment is due to reasonable cause and circumstances beyond the
taxpayer’s control; or
2. There was an unintentional error in the payment made by taxpayer, and the payment for the proper
amount due is made within 10 days.
Section 1 : Taxpayer Information
2. Legal Business Name
7. Mailing Address (Street, City, State, Zip)
Section 2 : Penalty Information
A. Tax Type(s)
B. Tax Year(s)
C. Quarter/ Month
Month*
1.
2.
3.
4.
5.
6.
10/2019
PAGE 1 of 3
Continue to Section 3 on Page 2
*If the tax is due monthly, enter the month only. If it is a quarterly tax, enter the quarter only (e.g.
FIRST, SECOND). Refer to the chart below.
Amusement Tax
Parking Tax
Monthly Tax Types
Quarterly Tax types
First-Jan-Feb-Mar
Second-Apr-May-Jun
Third-July-Aug-Sep
Fourth-Oct-Nov-Dec
Institution & Service
Privilege Tax- ONLY
ENTER THE TAX YEAR
in column B
(if you are requesting a waiver for more than one tax type or for more than one
period, be sure to list each separately. Attach additional sheets if necessary.)
Month
01-Jan 02-Feb 03-Mar
04-Apr 05-May 06-Jun
07-Jul 08-Aug 09-Sept
10-Oct 11-Nov 12-Dec
Local Service Tax
Facility Usage Fee
Payroll Expense Tax
7. TOTAL Requested Penalty AmountTOTAL Requested Penalty Amou :
(add lines 1D through 6D)
Quarter
Annual Tax Types
City of Pittsburgh
Department of Finance
414 Grant Street
Pittsburgh, PA 15219
Assistance? Call: (412) 255-8822
Email: [email protected]
Fax: (412) 255-6821
City of Pittsburgh
Department of Finance
414 Grant Street
Pittsburgh, PA 15219
Assistance? Call: (412) 255-8822
Email: [email protected]
Fax: (412) 255-6821
REQUEST FOR PENALTY WAIVER
Business Tax Only
PAGE 2 OF 3
10/2019
Section 3 : Reasonable Cause
Section 4 : Signature (REQUIRED)
2. Print Taxpayer's Name
3. Title
4. Phone Number
5. Date
Penalty Waiver Request, City Treasurer
Department of Finance
If you require additional information regarding a Penalty W
aiver, please call Taxpayer Services at 412-255-8822.
1. First Time Abatement
2. Death, serious illness, incapacitation or unavoidable absence of the taxpayer or a member of the
taxpayer's immediate family
3. Destruction of your records due to fire, casualty,natural disaster, or other disturbance
4. Could not make payment or deposit due to civil disturbance (e.g. mail strike or a riot)
5. Unable to determine amount of tax for reasons beyond your control
6. Received incorrect advice from a tax professional
7. Other
Explain:_____________________________________________________________________
FOR OFFICE USE ONLY
Submitted By:
Submittal Date:
Treasurer's Decision
Reason for Approval/ Denial
Treasurer's Signature:
Date
1.
Taxpayer's Signature
Reasonable Cause: is any sound reason for failing to file a tax return or pay the tax when due. A lack of funds,
in and of itself, is not reasonable cause for failure to file or pay on time.
Select from the following reasons to explain why you were unable to remit your tax payment timely:
Documentation & Criteria to Support your Claim: provide documentation to support your claim such as:
- Hospital or court records or a letter from a physician to establish illness or incapacitation, with specific start and
end dates
- Documentation of natural disasters or other events that prevented compliance
Additional Information to Prove Reasonable Cause: If your situation is not listed above select "
other" and provide short explanation. The
Finance Department will contact you if additional information is needed for your penalty abatement request.
I, the undersigned, do hereby certify that this document has been examined by me and to the best of my
knowledge is accurate and complete.
First Time Abatement Criteria: The Finance Department will remove penalties from your tax debt. To qualify, you must meet the
following criteria:
a.
you incurred no penalties or penalty abatement for 3 prior tax years.
b. you have filed all required returns.
c. you have made payment arrangements on your outstanding debt.
Submission of Penalty Waiver Form
After completing and signing this Penalty Waiver Form, please submit the form to:
Email : [email protected]
Mail :
414 Grant Street
Explanation: Explain why you believe this request should be approved. If you need more space, attach additional sheets.
Pittsburgh, PA 15219-2476
City of Pittsburgh
Department of Finance
414 Grant Street
Pittsburgh, PA 15219
Assistance? Call: (412) 255-8822
Email: [email protected]
Fax: (412) 255-6821
REQUEST FOR PENALTY WAIVER
Business Tax Only
Section 5: Additional Penalty Information (use this section to list additional penalty requests)
A. Tax Type(s)
B. Year
C. Quarter/Month*
D. Amount of Requested Penalty
22. Subtotal (add lines D8 through D21)
*If the tax is due monthly, enter the month only. If it is a quarterly tax, enter the quarter only (e.g. FIRST,
SECOND). Refer to the chart below.
Monthly Tax Types:
Month:
Amusement Tax
Parking Tax
01-Jan 02-Feb 03-Mar
04-Apr 05-May 06-Jun
07-Jul 08-Aug 09-Sept
10-Oct 11-Nov 12-Dec
Annual Tax Types
Institution & Service Privilege
Tax- ONLY ENTER THE TAX
YEAR in column B
Quarterly Tax Types:
Quarter:
First-Jan-Feb-Mar
Second-Apr-May-Jun
Third-July-Aug-Sep
Fourth-Oct-Nov-Dec
Local Service Tax
Facility Usage Fee
Payroll Expense Tax
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
10/2019
PAGE 3 of 3
23. Total Requested Penalty Amount (add #7 total and #22 subtotal)
21.
