Refund Application - Emergency And Municipal Services Tax Form
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1REFUND APPLICATION - EMERGENCY AND MUNICIPAL SERVICES TAX
(Local Tax Enabling Act, Act 511 as amended by Act 222)
___________________________
NAME:
Primary Employer:______________________
___________________________
Address:
__________________________
ADDRESS:
___________________________
__________________________
___________________________
__________________________
: ________________
$_______
_
________
Social Security Number
Refund Requested
Year:
Multiple Payment of Tax (Proof of duplicate payment must be provided)
Date Paid Amt. Paid Municipality to which tax was paid
Employer's Name & Address
Gross Income Under Taxable Limit
If your total income, from all sources, including those monies earned outside the City of Scranton is
less than $12,000, for the period January 1 through December 31, of the year indicated above,
complete section below.
Period of Employment
Total Income
Employer's Name & Address
$
$
$
$
$
Net profits from self employment
Other Income - Social Security, Unemployment Compensation, Pension, Dividends, Interest,
$
Workers Compensation, disability income, lottery winnings, etc.
TOTAL
$
$0.00
Proof of income must be attached to this form (i.e. copies of all W-2's, 1099's, income tax forms filed with the IRS
and/or PA Dept. of Revenue).
___________________________________________________________________
Signature
Date
I declare under the penalties provided by law that this application has been examined by me and is to the best of my
knowledge and belief true and correct.
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