Employer Refund Request Form - Lancaster County Tax Collection Bureau printable pdf download

Employer Refund Request Form - Lancaster County Tax Collection Bureau

Lancaster County Tax Collection Bureau

1845 William Penn Way Suite 1

Lancaster, PA 17601-6713

Phone: (717) 569-4521

Fax: (717) 569-1623

email:

EMPLOYER REFUND REQUEST FORM

Please complete refund request form in full, including an explanation, and email, mail or fax to our Bureau

Company Name: ______________________________________________________________________

Account Number (Optional):_________________________ FEIN: ____________________________

Address

____________________________________________________________________________________

Contact Name: ____________________________________ Phone Number:_____________________

Reason for Refund

Account Overpaid:

Total Taxes Remitted

$_____________

Overpayment: $__________________

(Including Overpayment)

Amended Total

$_____________

(Excluding Overpayment)

Quarter/Year: _______/____________

Taxes Remitted in Error:

Amount Remitted in error: $_________________

Check Number(s): __________________________________

Quarter/Year: _______/___________

__________________________________

Employee(s) Remitted in Error:

Employee Names/Social Security Number:

(Please attached additional employees on a separate sheet of paper)

__________________________________

Total Remitted in Error: $______________________

__________________________________

Amended Reconciliation Total: $___________________

__________________________________

Tax Year/Quarter: _______/____________

Other/Miscellaneous

Refund Amount: $_______________

Quarter/Year: ______/_________

Explanation: __________________________________________________________________________________

_____________________________________________________________________________________________

Employer Refund Request Form - Lancaster County Tax Collection Bureau