Application For Refund Of Local Services Tax Form - 2012 Page 2
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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.
Primary Employer (1)
Secondary Employer (2)
Employer (3)
Employer Name
Address
Address 2
City, State, Zip
Municipality
Phone
Start Date
End Date
Status (FT or PT)
Gross Earnings
LST Paid
Employer (4)
Employer (5)
Employer (6)
Employer Name
Address
Address 2
City, State, Zip
Municipality
Phone
Start Date
End Date
Status (FT or PT)
Gross Earnings
LST Paid
PLEASE NOTE:
All information received by the Tax Collector is CONFIDENTIAL and is only used for offi cial purposes relating
to the collection, administration and enforcement of the LOCAL SERVICES TAX.
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