Application For Emst/opt Refund Form printable pdf download

WEST SHORE TAX BUREAU

3607 ROSEMONT AVENUE, PO BOX 656

CAMP HILL PA 17001-0656

APPLICATION FOR EMST/OPT REFUND

This refund is for tax year __________________.

This application must be presented to West Shore Tax Bureau for refund approval.

Attach evidence of EMST/OPT deduction from employer or, if self employed provide a receipt of a copy of

your cancelled check.

Check one: Employer Deduction ___________

Self Employed ___________

W-2’s must be attached if applying for a refund under numbers 2 below.

PA-40 and all supporting documentation must be attached if applying for a refund under number 4 below.

This application must be signed and dated.

No refunds will be made until proper documents have been produced.

This form is to be used only for refund of EMST/OPT collected by the West Shore Tax Bureau and imposed

by those shown on the reverse side of this form.

Name: _____________________________________ Soc Sec #: ____________________________________

Address: ___________________________________

Phone #: _____________________________________

City/State: _________________________________

Zip: _________________________________________

Primary Employer/Location

Secondary Employer/Location

__________________________________________

REASON FOR CLAIM

1. _______ MULTIPLE DEDUCTIONS: Attach copies of pay stubs, W2’s or other proof of payment.

2. _______ NOT ENGAGED IN BUSINESS OR OCCUPATION IN PA:

Total earnings in Municipality: $_______________

Municipality: ________________________________

Earnings Elsewhere: $_________________________

Other Location: ______________________________

3. _______ UNDER AGE LIMIT: Only as ordinance applies. Proof of age is required.

4. _______ TOTAL TAXABLE INCOME LESS THAN APPLICABLE EXEMPTION DURING TAX

YEAR ENDING 12/31/__________.

PA-40 and all supporting documentation must be attached.

**Refund requested from (Employer Name): _______________________________________

I DECLARE UNDER PENALTY OF LAW THAT THE INFORMATION STATED HERE IS TRUE

AND CORRECT:

SIGNATURE: _________________________________________________ DATE: ____________________

Application For Emst/opt Refund Form