Emst Refund Request Form - York Adams Tax Bureau
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1York Adams Tax Bureau
Tax Collection Services
1415 N. Duke St., PO Box 15627
York, PA 17405-0156
Phone (717) 854-8084 Fax (717) 854-6376
EMST REFUND REQUEST FORM
•
This application must be presented to the York Adams Tax Bureau for approval.
•
Attach evidence of EMST deduction from employer or, if self-employed, provide a copy of your
cancelled check.
This refund is for calendar year __________________.
Check one: Employer Deduction [ ]
Self-Employed [ ]
•
W-2’s or pay stubs MUST be attached if applying for a refund under numbers 1 or 2 below.
•
PA-40 and all supporting documentation MUST be attached if applying for a refund under
number 4 below. No refunds will be issued until supporting documentation has been provided!
Name:_______________________________________
Social Security #:_________ - _____ - _________
Address:________________________________________________________________________________________
City, State, Zip:______________________________________
Phone: (_______) ________ - ____________
1
Employer:__________________________________
1
Municipality:_____________________________
ST
ST
2
Employer:__________________________________
2
Municipality:_____________________________
ND
ND
(Use back of form for additional employers)
I request a refund in the amount of $ _____________ of the ___________________________________ (enter
name of municipality) Emergency and Municipal Services Tax (EMST) for the reason indicated
below:
REASON FOR CLAIM
1.
[ ] MULTIPLE DEDUCTIONS: (Attach copies of W-2’s, paystubs or other proof of payment.)
2.
[ ] NOT ENGAGED IN BUSINESS OR OCCUPATION IN THIS MUNICIPALITY:
3.
[ ] UNDER AGE LIMIT: (Only as local ordinance applies. Proof of age required.)
4.
[ ] MY TOTAL TAXABLE INCOME FROM ALL SOURCES FOR TAX YEAR ___________
WAS BELOW THE EARNINGS THRESHOLD FOR THIS MUNICIPALITY. (As local
ordinance applies. Copy of PA-40 and all supporting documentation must be attached.)
I DECLARE UNDER PENALTY OF LAW THAT THE INFORMATION STATED ABOVE AND
DOCUMENTS SUBMITTED WITH THIS REQUEST ARE TRUE AND CORRECT TO THE BEST OF MY
KNOWLEDGE AND BELIEF.
SIGNATURE: ______________________________________________
DATE: _____________________
Do Not Write Below This Line
***************************************************************************************************************
_________ Your EMST refund request has been denied. Reason: ________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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