Application For Emst And Opt Refund Form Page 2
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1
2Employment Information: List all places of employment for the applicable tax year. Please list your
PRIMARY EMPLOYER under #1 below and your secondary employers under the other columns. If self
employed, write SELF under Employer Name column.
1. PRIMARY EMPLOYER 2.
3.
Employer Name
Address
Address 2
City, State Zip
Municipality
Phone
Start Date
End Date
Status (FT or PT)
Gross Earnings
4.
5.
6.
Employer Name
Address
Address 2
City, State Zip
Municipality
Phone
Start Date
End Date
Status (FT or PT)
Gross Earnings
PLEASE NOTE:
All information received by the West Shore Tax Bureau is considered to be CONFIDENTIAL and is only
used for Official Purposes relating to the collection, administration and enforcement of the Earned
Income and Emergency & Municipal Services Taxes.
I DECLARE UNDER PENALTY OF LAW THAT THE INFORMATION STATED HERE IS TRUE
AND CORRECT:
SIGNATURE: _________________________________________________ DATE: ____________________
Revised 3-07
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