Emergency Municipal Service Tax Refund Request Form
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1Emergency Municipal Service Tax Refund Request Form
The following information is required.
Name:
_____________________________
Date: __________________
Address:
_____________________________
Phone: _________________
_____________________________
_____________________________
Social Security #
_____________________________
Example: (Deduction taken by:
York Area Tax Bureau
On Date: 1/07/05
Municipality worked in:
North York Borough
In amt. of: $10.00
Reason for request:
Duplicate payment or earnings less than threshold for the year
st
1
Deduction taken by:
________________________________
On Date: __________
Municipality worked in:
________________________________
Tax Amount: ______
Reason for request:
______________________________________________________
nd
2
Deduction taken by:
________________________________
On Date: __________
Municipality worked in:
________________________________
Tax Amount: ______
Reason for request:
______________________________________________________
rd
3
Deduction taken by:
________________________________
On Date: __________
Municipality worked in:
________________________________
Tax Amount: ______
Reason for request:
______________________________________________________
th
4
Deduction taken by:
________________________________
On Date: __________
Municipality worked in:
________________________________
Tax Amount: ______
Reason for request:
___________________________________________________
A copy of a pay stub(s) indicating the deduction and/or evidence of deduction slip must be included with this request form
to verify each deduction listed above.
st
Refund requests are processed each month and refund checks are mailed the 1
Friday of the following month. *Please note
refunds can not be processed until the money is received from the employer(s) listed above.
If there are any questions, contact our office at 717-854-8084.
Mail this completed form with the required proof of deductions to:
Refund Request
YATB Tax Collection Services
PO Box 15627
____________________________
Taxpayer’s Signature
York Pa 17405
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Parent category: Financial