Local Services Tax Application For Refund Form 2015
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2LOCAL SERVICES TAX (LST) APPLICATION FOR REFUND
BENSALEM TOWNSHIP AND SCHOOL DISTRICT
TAX YEAR: 2015
Instructions:
Application for refund must be signed and dated by applicant.
Applicants must attach proper documentation to this application; no refund will be approved without proper
documentation.
Application for refund must be filed with the Tax Administrator for Bensalem Township and Bensalem School
District, MuniServices, at the remittance address listed below.
Mail Completed Exemption Certificate To:
MuniServices, LLC ● 190 North Evergreen Avenue Suite 205 ● Woodbury, NJ 08096
Questions?
Phone: (800) 987-0999 ● Fax: (800) 987-5450 ● Email:
Website:
Name of Applicant:
________________________________________________________
Social Security #:
________________________________________________________
Address:
_________________________________________________________
City/State/Zip:
_________________________________________________________
Phone #:
________________________________________________________
Amount of Refund Requested: $______________________ (must be more than $1.00)
REASON FOR REFUND (CHECK ALL THAT APPLY
1. __________MULTIPLE EMPLOYERS: 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.
List all employers on the reverse side of this form.
2. __________TOTAL EARNED INCOME AND NET PROFITS FROM ALL SOURCES WITHIN BENSALEM
TOWNSHIP/SCHOOL DISTRICT WAS LESS THAN $12,000. Attach copies of your last pay statements or your W-2
form from all employers within Bensalem Township/School District for 2014. If you are self-employed, please attach a
copy of your PA Schedule C,F, or RK-1 for 2014. Note: This exemption only applies to the Bensalem Township
portion ($47.00) of the combined $52.00 LST rate.
3. __________ACTIVE DUTY MILITARY EXEMPTION: Please attach a copy of your orders directing you to active
duty status.
4. __________MILITARY DISABILITY EXEMPTION: Please attach a copy of your discharge orders and a
statement from the United States Veterans Administrator documenting your disability. Only 100% permanent
disabilities are recognized for this exemption.
5. __________OTHER (Explanation Required): ______________________________________________________
I declare under penalty of law that all statements made and documents submitted herein are true and correct to the best of
my knowledge and belief.
Signature __________________________________ Print Name____________________________ Date ____________
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