Claim For Refund Form - Emergency Municipal Services Tax - Allentown
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1TAX & UTILITY SYSTEMS
City of Allentown – 215 City Hall
435 Hamilton Street, Allentown, PA 18101-1699
(610) 437-7508
C
R
– E
M
S
T
LAIM FOR
EFUND
MERGENCY
UNICIPAL
ERVICES
AX
A
/
TTACH ALL APPLICABLE ORIGINALS AND
OR COPIES OF FORMS TO THIS FORM
I
:
NSTRUCTIONS
1.
Application must be SIGNED by applicant.
2.
Applications must be presented to City of Allentown, Tax & Utility Systems, for refund approval.
3.
Applications received by mail will be refunded and remitted timely (by mail) by the Office of Treasury & Accounting. You must
enclose a self-addressed, stamped envelope.
N
:
’
(
)
2
OTE
NO REFUND WILL BE ISSUED UNLESS THE EVIDENCE OF THE APPLICANT
S ORIGINAL CERTIFICATE AND COPY
IES
OF OTHER EMST
(
)
.
CERTIFICATE
S
ARE ATTACHED
N
: __________________________________________________
S
. S
. #: _________-_________-________
AME
OC
EC
A
: ________________________________________________
DDRESS
$
________________________________________________________
R
EFUND
________________________________________________________
R
EQUESTED
REASON FOR CLAIM
M
D
P
: Applicant retains employee’s “Evidence of Deduction Certificate” (
2) from
ULTIPLE
EDUCTION OR
AYMENTS
EMST
his/her principal employer (attach copy). City will retain original(s) of the “Evidence of Deduction Certificate” from
the applicant’s second or part-time employer(s) when requesting a refund. List employer(s) by status order, MW# or
QW# as indicated on the
2 form, and check (√) appropriate Work Status Indicator (full-time/part-time).
EMST
E
E
R
W
EMST P
MPLOYER
MPLOYER
EFUND
ORK
AID
E
N
MPLOYER
AME
S
B
A
#
Y
S
D
TATUS
USINESS
CCOUNT
EAR
TATUS
EDUCTION
ST
1
(Principal)
2
ND
RD
3
$12,000
: If your income, from all sources, including those monies
TOTAL GROSS EARNINGS WERE LESS THAN
ANNUALLY
earned outside the City of Allentown is less than $12,000 for the period January 1 through December 31, you are
exempt from payment of
. List all Employer Names and Applicant Wages received for each occupation.
EMST
N
: W2’s and all copy(ies) of Federal or State Returns must be provided.
OTE
E
MPLOYER
E
N
:
W
E
MPLOYER
AME
AGES
ARNED
B
A
#
USINESS
CCOUNT
I
.
DECLARE UNDER PENALTY OF LAW THAT THE INFORMATION HEREIN CONTAINED IS TRUE AND CORRECT
A
PPLICANT
S
__________________________________________________
D
: ___________________
IGNATURE
ATE
- F
U
B
T
& U
S
-
OR
SE
Y
AX
TILITY
YSTEMS
FAILURE TO INCLUDE ALL NECESSARY
Date Application Received: ____________________
FORMS AND DOCUMENTS WILL DELAY
.
THIS REFUND REQUEST
Application Received by: ______________________
Date Refund Approved:_______________________
REFUNDS WILL ONLY BE AUTHORIZED AFTER OUR OFFICE HAS RECEIVED PAYMENT FOR THE TAX
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