APPLICATION FOR REFUND FROM LOCAL SERVICES TAX

APPLICATION FOR REFUND FROM LOCAL SERVICES TAX
A copy of this application for a refund of the Local Services Tax (LST), and all necessary supporting documents, must be completed and presented to the tax office charged with collecting the Local Services Tax. This application for a refund of the Local Services Tax must be signed and dated. No refund will be approved until proper documents have been received.
Name
Soc Sec
Address

Address

Street Address Line 2

CityStateState / Province

Zip
Phone
REASON FOR REFUND - CHECK ALL THAT APPLY
I overpaid by more than 100
MULTIPLE EMPLOYERS Please attach a copy of a current pay statement from your principal employer that shows the name of the employer the length of the payroll period and the amount of Local Services Tax withheld Please list all employers on the reverse side of this form
TOTAL EARNED INCOME AND NET PROFITS FROM ALL SOURCES WITHIN
(municipality or school district) WAS : Please attach a copy of all of your last pay statements from all employers within the political subdivision for the year prior to the fiscal year for which you are requesting to be exempted from the Local Services Tax. If you are self-employed, please attach a copy of your PA Schedule C, F or RK-1 for the year prior to the fiscal year for which you are requesting to receive a refund of the Local Services Tax.
LESS THAN
ACTIVE DUTY MILITARY EXEMPTION Please attach a copy of your orders directing you to active duty status
MILITYARY DISABILITY EXEMPTION Please attach a copy of your discharge orders and a statement from the United States Veterans Administrator or its successor declaring your disability to be a total one hundred percent permanent disability
MILITYARY DISABILITY EXEMPTION: Please attach a copy of your discharge orders and a statement from the United States Veterans Administrator or its successor

declaring your disability to be a total one hundred percent permanent disability.
Tax Office
Address

Address

Street Address Line 2

CityStateState / Province

Zip
Phone #
Employment Information: List all places of employment for the applicable tax year. Please list your PRIMARY EMPLOYER under #1 below and your secondary employers under the other columns. If self-employed, write SELF under Employer Name column.

Status (FT or PT) Gross Earnings

Status (FT or PT) Gross Earnings

All information received by the Tax Collector is considered to be CONFIDENTIAL and is only used for official purposes relating to the collection, administration and enforcement of the LOCAL SERVICES TAX.
I DECLARE UNDER THE PENALTY OF LAW THAT THE INFORMATION STATED ON AND ATTACHED TO THIS FORM IS TRUE AND CORRECT:
SIGNATURE

Clear
DATE

MonthDayYear
Date
Should be Empty:

APPLICATION FOR REFUND FROM LOCAL SERVICES TAX

REASON FOR REFUND - CHECK ALL THAT APPLY

TOTAL EARNED INCOME AND NET PROFITS FROM ALL SOURCES WITHIN

LESS THAN

I DECLARE UNDER THE PENALTY OF LAW THAT THE INFORMATION STATED ON AND ATTACHED TO THIS FORM IS TRUE AND CORRECT: