Out Of State Refund Request Form - West Shore Tax Bureau printable pdf download

Out Of State Refund Request Form - West Shore Tax Bureau

West Shore Tax Bureau

3607 Rosemont Avenue

Camp Hill PA 17011

Telephone: 717.761.4900

Fax: 717.975.8955

OUT OF STATE REFUND REQUEST

DATE: ______________________

AS A NON-RESIDENT OF THE WEST SHORE TAX BUREAU’S TAXING

JURISDICTION, I AM REQUESTING A REFUND OF $____________________

WITHHELD BY ________________________________________(EMPLOYER)

FOR TAX YEAR ___________ .

SOCIAL SECURITY #

___________________________________________

CONTACT PHONE #

___________________________________________

TAXPAYER NAME

___________________________________________

SIGNATURE

___________________________________________

PLEASE ATTACH THE FOLLOWING SUPPORTING DOCUMENTATION:

__________

EMPLOYER W-2’S

__________

COPY OF RESIDENT STATE FILING

__________

COPY OF RESIDENT LOCAL FILING

__________

COPY OF RESIDENT STATE DRIVER’S LICENSE

__________

COPY OF PA STATE FILING

__________

COPY OF PA SCHEDULE G

Official use only.

PSD _________

Please return completed form to:

West Shore Tax Bureau

P O Box 656

Camp Hill, PA 17001

Out Of State Refund Request Form - West Shore Tax Bureau