Fillable Emergency And Municipal Services Tax Refund Request Form

Emergency And Municipal Services Tax Refund Request Form - 2007

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UPPER DUBLIN TOWNSHIP

801 Loch Alsh Avenue

2007

Fort Washington, PA 19034-1697

FINANCE DEPARTMENT

Phone: (215) 643-1600, Ext. 3325

Fax: (215) 542-0797

Emergency and Municipal Services Tax

Refund Request Form

SSN:

Name:

Address:

Refund

Requested

Refund of Emergency and Municipal Services Tax (EMST) is requested for the following reason:

DUPLICATE PAYMENTS WERE MADE:

TOTAL EMST PAID SHOULD NOT EXCEED THE MAXIMUM LIMIT OF $52 ANNUALLY.

I am entitled to a refund for the amount of EMST that I paid in excess of $52.

Township of Deduction

EMST Paid/Deducted

Dates Employed in 2007

Employer

1st

2nd

3rd

MUST attach Proof of duplicate payment (for example, pay stubs.

TOTAL GROSS EARNINGS WERE LESS THAN $12,000 ANNUALLY:

A TAXPAYER WHOSE TOTAL GROSS INCOME FROM ALL SOURCES

IS LESS THAN $12,000 ANNUALLY IS EXEMPT FROM PAYMENT OF THE EMST.

I am entitled to a refund for the total amount of EMST I paid. I understand that TOTAL GROSS INCOME IS THE TOTAL OF

ALL COMPENSATION DERIVED FROM ALL SOURCES. 'TOTAL GROSS INCOME' PA40 line 1C + PA40 line 4.

- -

I am requesting a refund from Upper Dublin Township for the total amount of EMST I paid because my TOTAL GROSS

INCOME was less than $12,000 annually.

MUST attach copies of all W2(s) AND page 1 of both Federal and State Tax Returns.

If self-employed, MUST also attach copies of all Schs C, E, K-1 AND Proof of individual payment.

OTHER:

Copies of all appropriate documents must be enclosed:

FAILURE TO INCLUDE ALL NECESSARY

AND

1.) W2(s) and/or Sch C, E, K1 if self-employed

FORMS AND DOCUMENTS WILL DELAY

2.) Pay stub(s) and/or proof of payment if self-employed

AND

THIS REFUND REQUEST.

3.) Federal and State Income Tax Returns (page 1 of both)

REFUNDS WILL ONLY BE AUTHORIZED AFTER OUR OFFICE HAS RECEIVED PAYMENT FOR THE TAX.

Signature:

Date:

Printed Name:

Phone Number:

Taxpayers are entitled to receive a written explanation of their rights with regards to the assessment, audit, appeal, enforcement, refund and

collection of certain taxes administered by the Township. A written explanation entitled ''Township of Upper Dublin Taxpayer's Bill of Rights

Disclosure Statement'' has been prepared for this purpose and is available without charge from the township finance department.

Emergency And Municipal Services Tax Refund Request Form - 2007

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