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CITY OF PITTSBURGH

ACT 77 -- PROPERTY TAX RELIEF APPLICATION FOR 2013

This is a two-sided form. Complete both sides of this application.

Print the following information:

|Property Owner Name: |

|Street Address: |

|City State Zip Code |

|Property Tax Account Number as it appears on your tax bill: |

| | | | | | | | | | | | | | | | | | | |

1) Property Address ________________________ Date purchased ____________

Is the property used as your principal residence? Yes ( ) No ( )

How many years have you occupied the property? ________________

2) Does anyone beside you and your spouse own this house? Yes ( ) No ( )

Does this other owner live with you? Yes ( ) No ( ) Does Not Apply ( )

If No, what is their address?_____________________________________________

3) If not owned and occupied for at least 10 consecutive years, what property did you OWN and OCCUPY in Allegheny County as your principal residence prior to purchasing your current residence?

Address______________________________________ Date Purchased _________________

Ward or Municipality____________________________ Block & Lot_____________________

4) What is your date of birth?_______________________ (attach proof)

5) What is your spouse’s date of birth?________________ (attach proof)

6) Are you or your spouse permanently disabled and age 18 or older (you must

provide proof of disability). Yes ( ) No ( )

Check here if Spouse is Deceased ( ) Date of Death____________________

CITY OF PITTSBURGH

ACT 77 -- PROPERTY TAX RELIEF APPLICATION FOR 2013

SIDE TWO

Did you file a 2011 State Property Tax Rebate application? Yes ( ) No ( )

Did you file a 2011 Federal Tax Return? Yes ( ) No ( )

List below AND enclose proof of your household income for the year 2011:

You must complete this section and include proof of income of all owner occupants or we cannot

process your application. You must attach copies of your State Property Tax Rebate Form or

Federal Tax Return, W-2 forms and Social Security Statements. Do not send your original documents. Income may be compared to IRS records.

1) GROSS SALARY, WAGES, BONUSES, COMMISSIONS $ _______________

2) 50% OF SOCIAL SECURITY, SSI & RAILROAD RETIREMENT $ _______________

BENEFITS (reported on the blue and white Form RRB-1099)

3) PENSIONS, ANNUITIES AND IRA DISTRIBUTIONS $ _______________

4) INTEREST, DIVIDENDS & CAPITAL GAINS $ _______________

5) BUSINESS INCOME, SELF-EMPLOYMENT INCOME, RENTAL INCOME $ _______________

6) ALIMONY OR SUPPORT, UNEMPLOYMENT, WORKERS COMPENSATION $ _______________

7) OTHER INCOME (ATTACH A SCHEDULE & EXPLANATION) $ _______________

TOTAL HOUSEHOLD INCOME (ADD LINES 1 THROUGH 7) $ _______________

I certify that this claim is true, correct and complete to the best of my knowledge and belief. An excessive

claim made with fraudulent intent can subject the claimant to a misdemeanor punishable by law.

Claimant’s Signature Date

Preparer’s Signature Date

_____________________________

Claimant’s Home Phone Number Work Phone Number

In order to apply the reduction to your 2013 taxes attach proof of 2011 income and return completed application as soon as possible but no later than the filing deadline of July 31, 2013 to:

City Of Pittsburgh

Act 77 -- Senior Tax Relief

414 Grant Street

Pittsburgh, PA 15219

Phone: 412 255-2525

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