Application For Refund Of Local Services Tax Form

2012

LOCAL SERVICES TAX – REFUND APPLICATION

Business Tax Ofﬁ ce

Upper Merion Township

175 West Valley Forge Road

King of Prussia, PA 19406

Phone: 610-265-2600

Fax: 610-265-0482

APPLICATION FOR REFUND OF LOCAL SERVICES TAX

• A copy of this application for a refund of the Local Services Tax (LST), and all necessary supporting

documents, must be completed and presented to the tax ofﬁ ce charged with collecting the Local Services Tax.

• This application for a refund of the Local Services Tax must be signed and dated.

• No refund will be approved until proper documents have been received.

Name: _________________________________________________ Soc Sec #: _________________________________

Address: _______________________________________________ Phone #: __________________________________

City/State: ______________________________________________ Zip: ______________________________________

Amount of refund requested: $____________________ (must be more than $1)

REASON FOR REFUND – CHECK ALL THAT APPLY

1. ______ I had the tax withheld when it should have been exempted. (Attach a copy of exemption certiﬁ cate ﬁ led with

employer.)

2. ______ I had tax withheld by multiple employers. (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. List all employers on the reverse side of this form.)

3. ______ My total earned income (including tips) and net proﬁ ts from all sources within Upper Merion Township

was less than $12,000 for the tax year. (Attach a copy of all your last pay statements from all employers

within Upper Merion Township for the tax year for which you are requesting a refund of Local Services Tax. If

you are self-employed, attach a copy of your PA Schedule C, F, or RK-1 for the year for which you are requesting

to receive a refund of the Local Services Tax.)

4. ______ I am on active military duty. (Attach a copy of your orders directing you to active duty status.)

5. ______ I am a veteran with a qualifying disability. (Attach a copy of your discharge orders and a statement from the

United States Veterans Administration declaring your disability to be a total one hundred percent permanent

disability.)

I declare under penalty of law that all statements made and documents submitted herein are true and correct to the best of

my knowledge and belief.

Taxpayer Signature: ______________________________________ Date: _____________________________________

Refund application and required supporting documents shall be mailed to Upper Merion Township at the address shown

above to the attention of Michele Delli Pizzi, Director of Accounts Receivable.

Questions? Call 610-265-2600 ext. 211, 224, or 227.

Application For Refund Of Local Services Tax Form - 2012