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Emergency & Municipal Services Tax Refund Form - Pittsburgh Department Of Finance - 2005

CITY OF PITTSBURGH

DEPARTMENT OF FINANCE

EMERGENCY & MUNICIPAL SERVICES TAX

REFUND FORM - 2005

A copy of the EM-2 receipt or copies of both your pay stubs with your name and the employer name

printed on it, and/or a letter from your employer(s) on company letterhead will be accepted as proof

of payment.

If multiple payments were paid to the City of Pittsburgh – a refund will apply only with proof of EM-2

payments. If multiple payments were paid, one to the City of Pittsburgh and one or more to another

municipality, the principal job will determine refund. EM-2 receipts(s) and pay stubs required.

CHECK ONE –

IF FORM IS NOT COMPLETED CORRECTLY YOUR REQUEST COULD BE DENIED.

Multiple payment. Enter names of employers in the blocks below and attach proof.

_____

Refund will depend on your principal job as of January 2005 or when you are first employed.

_____ Gross earnings for the tax year 2005 were under $12,000.00. Enclose copies of your W-2(s)

from all employers for year 2005, and a copy of your Federal 1040 form for 2005 including joint

returns.

_____ Self-employed, enter your City Account Number ________________________________

_____ Paid directly to the City under your Social Security number ______________using Form EM-3.

_____ Employer refund. Enclose copy of your cancelled check (front & back) include your City

Account Number and attach letter of explanation.

_____ Do not work in the City of Pittsburgh, withheld in error by employer.

EMPLOYER NAME

EMPLOYER PHONE NUMBER

AMOUNT WITHHELD

Principal Employer

Employer

Other

YOUR SOCIAL SECURITY NUMBER

AMOUNT REQUESTED

YEAR REQUESTED

COMPLETE A SEPARATE FORM FOR EACH YEAR REQUESTED

I hereby certify, swear and aver that all statements herein are true and correct to the best of my knowledge and belief,

being duly apprised of my duty under the law to submit honest and complete information or be subject to the penalties

provided by law.

SIGNATURE __________________________________

PHONE ________________________

ADDRESS _______________________________________________________________________

CITY/STATE/ZIP __________________________________________________________________

Questions call 412-255-8629 or 412-255-2510.

MAIL TO: CITY TREASURER – EM REFUND REQUEST – 414 GRANT ST RM 207 – PITTSBURGH PA 15219

Emergency & Municipal Services Tax Refund Form - Pittsburgh Department Of Finance - 2005