Application For 2007 Emst Refund Form - Capital Tax Collection Bureau printable pdf download

Capital Tax Collection Bureau

Central Dauphin Division

Harrisburg Division

Carlisle Division

425 PRINCE ST

2301 N 3RD ST

19 S HANOVER ST STE 102

HARRISBURG PA 17109-1734

HARRISBURG PA 17110-1893

CARLISLE PA 17013-3336

(717) 545-2791 Phone

(717) 234-3217 Phone

Phone (717) 243-3725

(717) 545-3028 Fax

(717) 234-2962 Fax

Fax (717) 243-9224

FOR HARRISBURG DIVISION ONLY

APPLICATION FOR 2007 EMST REFUND

DIRECTIONS: Complete the personal information (below) and employment information section (on reverse), check the

appropriate section A through E, sign and date this application and submit along with any other requested documentation

to the Capital Tax Collection Bureau, Harrisburg Division listed above.

Personal Information (please print or type):

Name___________________________________________________

Soc. Sec. No.______/_____/______

Home Address_____________________________________________________________________________

I request a refund of the _____________________________ (enter name of municipality) EMST for the reason

checked below. PLEASE NOTE: In EVERY case below you must submit proof of payment of ALL EMST

that you claim to have paid. Examples of proof of payment are: Form EMST-2 (Certificate of Deduction)

issued by the employer, a payroll check stub clearly identifying the deduction, and/or a receipted EMST-3 Form

(Personal Billing for EMST) or cancelled check making personal payment.

A ___ I paid two or more EMST’s for this tax year to the taxing jurisdiction named above.

B ___ I paid an EMST for this tax year on my principle occupation listed on line________ of the "Employment

Information" section of the reverse of this sheet. I paid $________ in total EMST from all sources which

exceeds the $52 levy by $________ which I am requesting a refund.

C ___ I paid an EMST to the municipality listed above but I am not engaged in an occupation within this

municipality.

D ___ The occupation for which the EMST was paid was for that of a clergy person.

E ___

I paid an EMST to the taxing jurisdiction named above for this tax year but quality for exemption from this tax

based on the taxing jurisdiction’s exemption guidelines provided in bold at the end of this section. All sources

include all income reported on your PA-40 return and adjusting for the gross receipts from your Schedule C, K-1

or F and not the net that was reported on PA-40. You must provide copies of your PA-40 for the year that you are

requesting a refund. If you filed a joint PA-40 with your spouse you must provide copies of all W-2s and

supporting schedules. Interest and dividends will be allocated at a 50/50 split unless you can prove otherwise.

(Income Exemptions: Harrisburg City less than $10,000 gross income from all occupations and businesses

within the City of Harrisburg, Marysville Boro, Highspire Boro & Penn Twp. [Perry Co.] less than

$12,000 gross income from all sources, Bloomfield Boro less than $6,000 earned income or age 70 ,

Newport Boro less than $1,000 gross income from all sources, Steelton Boro less than $1,000 gross income

from all occupations within the Borough, Watts Twp. worked 10 or less days in the Township.)

Under penalties of perjury I declare that to the best of my knowledge and belief, the above statements and

documents submitted with this request are true, correct, and complete.

Signature _________________________________________

Date _____________________

Application For 2007 Emst Refund Form - Capital Tax Collection Bureau

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