Local Services Tax Form - Refund Application Page 2
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1
2Employment Information: List all places of employment for the applicable tax year. Please list your
PRIARY EMPLOYER under #1 below and your secondary employers under the other columns. If
self-employed, write SELF under Employer Name column.
Employer Name
Address
Address 2
City State Zip
Municipality
Phone
Start Date
End
Date
Status (FT or PT)
Gross Earnin2s
1. PRIMARY EMPLOYER 2.
3.
.
.
.
Employer Name
Address
Address 2
City State Zip
Municipality
Phone
Start Date
End Date
Status (FT or PT)
Gross Earnin2s
4
s
6
PLEASE NOTE:
All information received by the Tax Collector is considered CONFIDENTIAL and is only used for
official purposes relating to the collection, administration and enforcement of the LOCAL SERVICES
TAX.
I DECLAR UNDER THE PENALTY OF LAW THAT THE INFORMATION STATED ON AND
ATTACHED TO THIS FORM IS TRUE AND CORRCT:
SIGNATURE:
DATE:
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