Application for Exemption from 2011 Per Capita Tax

MONAGHAN TOWNSHIP APPLICATION FOR EXEMPTION FROM 2011 PER CAPITA TAX

INSTRUCTIONS: (This form must be completed and submitted for tax year 2011).

If you are requesting an exemption for the reason that your total annual income for the year 2010 is less than $5,000.00, you must complete Section A, Section B and Section D. The application must be completed after December 31, 2010, and the application, with any necessary documentation, must be submitted to the Monaghan Township Tax Collector not later than March 31, 2011.

Military personnel on active duty and stationed outside of the boundaries of Monaghan Township must complete Section A, Section C and Section D. The completed application may be submitted to the Monaghan Township Tax Collector at any time after June 30, 2011, but not later than October 15, 2011 for the exemption to be approved for the current year and for the payment of the 2011 Monaghan Township Per Capita Tax to be waived. Exemption applications submitted after October 15, 2011 will be considered for a refund only and must be submitted not later than March 31, 2011 . Active duty service and station outside the boundaries of Monaghan Township must be concurrent and exclusive to the calendar year, 2011.

SECTION A:

Name ______SS# ______

Address ______Zip ______

Present employer ______

Your phone no. ______Employer phone no. ______

SECTION B:

Please list all sources of income for the past year (January 1 through December 31).

Salary or Wages $______Alimony/Child Support $______

Public Assistance $______Rental Income $______

Unemployment $______Pensions $______

Workman's Comp $______Interest and Dividends $______

Self-Employment$______Disability $______

Social Security $______Other income (explain) $______

TOTAL INCOME $______SECTION C:

In addition to the following information, please provide a photocopy of your military identification card.

Armed Services - Branch or Service: ______

Station: ______

Dates of Active Duty Service for year 2000______Dates stationed as above: from ______until ______

SECTION D:

I HEREWITH AFFIRM THAT THE STATEMENTS GIVEN IN THIS APPLICATION ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

______Signature of Applicant Date

**Please remember to submit proof of income.

TOWNSHIP USE ONLY

To be completed by Tax Collector

The applicant for this exemption has _____ has not _____ remitted the Per Capita tax to me.

______Tax Collector Signature Date

To be completed by Township Secretary

Application received ______Date

Income verification ______

E I T cross reference______