Central Tax Bureau Of Pennsylvania Form
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1Central Tax Bureau
of Pennsylvania, Inc.
OFFICE USE ONLY
Approved ________Rejected ________
By_______________Date___________
Reason Rejected _________________
_______________________________
Date Issued ______Check No. ______
FORM MUST BE COMPLETED IN FULL AND VERIFIED BEFORE REQUEST WILL BE CONSIDERED
(Print or type)
Taxing District: __________________________________
_____________________________________________________
Type of Tax: _____________________________________
Name of Applicant
_____________________________________________________
Refund Requested: $ ______________________________
Street Address
Employer’s Name and Address:
_____________________________________________________
City,
State
Zip
________________________________________________
_____________________________________________________
________________________________________________
Resident Municipality
Social Security Number
I hereby request a refund of the above tax for the following reason(s):
My annual income from ALL sources was $_________________.
(Attach schedule showing all
sources of income and the amounts, W-2’s, Schedule C’s, or other supporting data.)
Duplicate payment. (Attach original withholding statements).
Date of Payments
(1) _______________________
(2) ___________________________
Amt. of Payments
(1) _______________________
(2) ___________________________
Employer paid by
(1) _______________________
(2) ___________________________
District paid to
(1) _______________________
(2) ___________________________
Overpayment:
Total Taxable Income $ _____________Total Tax Due $ _____________ Total Paid $____________
Underage:
Birth Date: _______________________
Other (explain in full):_________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
I hereby certify that the above information is true and correct and acknowledge full responsibility for repayment
of any taxes erroneously refunded to me.
Date:_________________________ Signature:__________________________________________________
LOCAL TAXPAYER BILL OF RIGHTS
You are entitled to receive a written explanation of your rights with regard to the audit, appeal, enforcement, refund and
collection of local taxes by calling the political subdivision to which these taxes apply during their normal business hours.
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