INSTRUCTIONS: This form is to be used by taxpayers seeking an initial claim for refund from Upper Providence Township. Taxpayers whose initial refund claim has been denied and are appealing such denial, must file a Petition for refund with the Upper Providence Township Council. Please compete this form using blue or black ink, or type this form. Attach proof that the tax for which you are seeking a refund was paid. For all taxes, mail this form to the attention of Upper Providence Township Council, Township Municipal Building, 935 N. Providence Road, Media, PA 19063 (hereinafter the “Tax Administrator”). Refund Claims must be received by the Tax Administrator within the later of: (a) three years of the due date for filing the tax return; or (b) one (1) year after actual payment of the tax. Refund Claims filed via U.S. Postal Service are considered filed as of the postmark date. Refund Claims filed via any other method are considered filed on the date received. Answer all questions below as completely as possible. If an item is not applicable, enter “N/A”.

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Last Name                              First Name                                    Middle Initial
 

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Street Address                            City                    State           Zip                     County
 
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Phone Number Fax Number

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Previous Address                       City                   State           Zip                      County

Social Security Number _______________________________

State the date taxpayer(s) established domicile in the District. ______________

TAX INFORMATION

Type of Tax EMS                                          Amount of Refund Claim:  $47.00

Tax Year: __________________                  Township: Upper Providence

School District: Rose Tree Media                 County: Delaware

Explain in detail why the Refund Claim requested above should be granted. Attach additional pages if necessary. Enclose copies of any documents you feel will support your arguments. Refund Claims must be accompanied by proof of payment of tax.

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SIGNATURE

All Refund Claims must be signed by the taxpayer and be accompanied by the following penalty of perjury statement.

Under penalties prescribed by law, I hereby certify that this Refund Claim has been examined by me and that to the best of my knowledge, information and belief, the facts contained in the refund Claim are true and correct.

Signature:___________________________________ Date:_________________________________

Print Name: _________________________________