Attachment_H_-_NSFUF_Form_2023.pdf

UF-1 2023 NON-RESIDENT SPORTS FACILITY

USAGE FEE

CITY OF PITTSBURGH

Rev 11/22

ACCOUNT NO FEDERAL ID

QUARTER

CITY ID

Due on or before

USE BLACK INK ONLY ON THIS FORM – DO NOT STAPLE ANYTHING TO THIS FORM

EVENT DATE(S) EVENT FACILITY

COMPUTATION OF TAX

1. NO. OF EMPLOYEES FOR WHOM USAGE FEE IS BEING REMITTED

2. COMPENSATION ALLOCABLE TO PITTSBURGH (Includes all forms of compensation based on profits or otherwise, earned by a person or personal representative for services rendered in a publicly funded facility) .

3. AMOUNT DUE – (multiply Line 2 by 3% - (0.03) ) .

4. PENALTY – (City penalty 1% (0.01) per month or fraction thereof) .

5. TOTAL DUE (add Lines 3 through 4) .

Amounts under $2.00 are not due Make check payable to: TREASURER, CITY OF PITTSBURGH – DO NOT SEND CASH Mail to: USAGE FEE DUE – 414 GRANT ST RM 206 – PITTSBURGH PA 15219-2476

A $30.00 fee will be assessed for any check returned from the bank for any reason.

ATTACH A LIST INCLUDING THE SOCIAL SECURITY NUMBER, NAME, ADDRESS, PITTSBURGH INCOME AND THE

AMOUNT WITHHELD FOR EACH USER/EMPLOYEE/ENTERTAINER.

Refunds. Each user/employee/entertainer must pay the Usage Fee. The City of Pittsburgh will only issue refunds to the employer if the employer provides evidence that the Usage Fee was previously refunded to the user/employee/entertainer by the employer.

FOR ASSISTANCE CALL: 412-255-2525

${0004}_${0007}

06${0004}${1110}${0081}${21021}

Amended Return ( )

Supplemental Return ( )

SIGNATURE _____________________________________________

TITLE _____________________ DATE _______________________

PHONE _________________________________________________

E-MAIL ADDRESS ________________________________________

PREPARER’S NAME ______________________________________

PREPARER’S PHONE ______________________________________

I hereby certify, swear and aver that all statements herein are true and correct to the best of my knowledge and belief, being duly apprised of my duty under the law to submit honest and complete information or be subject to the penalties provided by law.

OMISSION OF THE ABOVE APPLICABLE INFORMATION

CONSTITUTES AN INCOMPLETE RETURN

PAGE 2 USAGE FEE – FOR PLAYERS OR PERFORMERS

CITY OF PITTSBURGH

Employee

Social Security Number

Address Income Usage Fee

3%

TOTAL

PAGE 3 USAGE FEE – FOR NON-PLAYERS OR STAFF

CITY OF PITTSBURGH

Employee

Social Security Number Posititon Address Income

Usage Fee 3%

TOTAL

FOR ASSISTANCE CALL: 412-255-2525