Form Lst Ref-2008 - Local Services Tax Refund Application For Tax Year printable pdf download

Form Lst Ref-2008 - Local Services Tax Refund Application For Tax Year

York Adams Tax Bureau

Tax Collection Services

1415 N. Duke St., PO Box 15627

York, PA 17405-0156

Phone (717) 854-8084 Fax (717) 854-6376

LOCAL SERVICES TAX – REFUND APPLICATION for tax year- ___________

This application for a refund of the Local Services Tax must be signed, dated and presented to

the YATB for approval. No refund will be approved until proper supporting documents have

been provided.

Name: _______________________________________ SSN#: _________________________

Address: _____________________________________ Phone #: _______________________

City/State: ___________________________________ Zip: ____________________________

REASON FOR REFUND – CHECK ALL THAT APPLY

1. __________ I overpaid by more than $1, for the ________ calendar year.

2. __________ I had the tax withheld when it should have been exempted.

3. __________ MULTIPLE EMPLOYERS: Please attach a copy of a current pay statement from your

principal employer that shows the name of the employer, the length of the payroll

period and the amount of Local Services Tax withheld. Please list all employers on the

reverse side of this form.

4. __________ TOTAL EARNED INCOME AND NET PROFITS FROM ALL SOURCES WITHIN

_____________________________________ (municipality or school district) WAS

LESS THAN $_____________: Please attach a copy of all of your last pay statements

from all employers within the political subdivision for the year prior to the year for

which you are requesting to be exempted from the Local Services Tax.

* If you are self-employed, please attach a copy of your PA Schedule C, F, or RK-1

for the year prior to the year for which you are requesting to receive a refund of

the Local Services Tax.

5. __________ ACTIVE DUTY MILITARY EXEMPTION: Please attach a copy of your orders

directing you to active duty status.

6. __________ MILITARY DISABILITY EXEMPTION: Please attach copy of your discharge orders

and a statement from the United States Veterans Administrator or its successor

declaring your disability to be a total one hundred percent permanent disability.

LST REF-2008

Form Lst Ref-2008 - Local Services Tax Refund Application For Tax Year