Local Services Tax - Refund Application - Wilkins Local Services Tax Office

Local Services Tax - Refund Application - Wilkins Local Services Tax Office - 2015 Page 2

Employment 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

Employer

Address

Address 2

City, State Zip

Municipality

Phone

Start Date

End Date

Status (FT or PT)

Gross Earnings

Employer

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 Tax Collector is considered to be CONFIDENTIAL and

is only used for official purposes relating to the collection, administration and enforcement of the

LOCAL SERVICES TAX.

I DECLARE UNDER PENALTY OF LAW THAT THE INFORMATION STATED ON AND

ATTACHED TO THIS FORM IS TRUE AND CORRECT:

SIGNATURE: _________________________________________________ DATE: ___________________

PRINT NAME: _________________________________________________TAX YEAR _______________

TAX OFFICE HOURS: Monday – Friday 9 a.m. to 4 p.m. (except holidays)

WILKINS LST OFFICE, 2700 MONROEVILLE BLVD. MONROEVILLE, PA 15146-2388

MONTAX@MONROEVILLE.PA.US

412 856 3333

C:\data\Monroeville\tax\forms\Wilk_LST\Wilkins LST-Refund Form.doc

9/17/2015

Local Services Tax - Refund Application - Wilkins Local Services Tax Office - 2015 Page 2