Form Lst Ref-2008 - Local Services Tax Refund Application For Tax Year 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
Term Date
Status (
or
)
FT
PT
Gross Earnings
4.
5.
6.
Employer Name
Address
Address 2
City, State Zip
Municipality
Phone
Start Date
Term Date
Status (
or
)
FT
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: ____________________
LST REF-2008
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