"Local Services Tax (Lst) - Refund Application Form"

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LOCAL SERVICES TAX (LST) – REFUND APPLICATION
Tax Year : ______________
I am requesting refund from the following LST: Municipality ______________________________________________
County ______________________________________________
Social Security No.
Daytime Phone No.
Employee Name:
Street Address:
City/State/Zip:
Instructions: Check & complete where necessary, the item number below that pertains to your refund request. Item
numbers 1-4 below result in a refund of both municipal & school portions of the tax, where applicable. Item number
5 often results in a refund of only the municipal portion of an LST. Refer to SCHEDULE I on the back of this form
to determine the amount of any possible refund for the Low-Income Exemption. In EVERY case below you must
submit proof of payment of ALL LST that you claim to have paid. Examples of proof of payments are: employer
issued W-2 Forms or payroll check stubs clearly identifying the deduction and the period thereof, and/or a receipted
LST-3 Form (Personal Billing for LST) or cancelled check making personal payment.
1. ___
MULTIPLE CONCURRENT OCCUPATIONS: Complete a refund request form (i.e., this form) for each different
Attach documents to verify, by the concurrent
concurrent period for which you are claiming a multiple payment.
period, LST amounts paid, earnings and/or net profits, and your principle occupation for such period.
Complete all the information below, listing your principle employer in Row “A.”
This refund request is for the concurrent period of: (begin date) ____________ through (end date) ____________
Date began
Earnings
LST payment
work in
during
amount for
LST payment
Employer name or “SELF” if
concurrent
concurrent
Taxing jurisdiction(s) for
concurrent
amount for
paid personally
period
period
whom LST was paid
period
entire tax year
A.
$
$
$
B.
$
$
$
C.
$
$
$
D.
$
$
$
2. ___
ACTIVE DUTY MILITARY EXEMPTION: Attach a copy of your orders directing you to active duty status for the year of
the refund request.
3. ___
CLERGY EXEMPTION: I paid an LST based on my occupation as clergy. Enter the name, address, phone number &
contact person & title for the church, temple, etc., for which you are/were employed: ________________________________
____________________________________________________________________________________________________
4. ___
MILITARY DISABILITY EXEMPTION: Please attach copy of your discharge orders and a statement from the United
States Veterans Administrator documenting your disability. Only 100% permanent disabilities are recognized for this
exemption.
5. ___
LOW-INCOME EXEMPTION (Refer to SCHEDULE I on the back of this form to determine appropriate entries for the
blanks below): Important Note: No “Low-Income Exemption” refunds will be processed until after the end of the tax
year.
My total earned income and net profits from all sources within the municipality of _____________________________ was
less than $_________ (Column C). I therefore qualify for a refund of $_________ (lesser of actual LST paid or Column B,
less amount in Column E) reducing my LST liability to $_________ (Column E).
I DECLARE UNDER PENALTY OF LAW THAT ALL THE INFORMATION STATED ON AND SUBMITTED WITH
THIS FORM IS TRUE, CORRECT AND COMPLETE:
Taxpayer Signature: __________________________________________ Date: ______________
LOCAL SERVICES TAX (LST) – REFUND APPLICATION
Tax Year : ______________
I am requesting refund from the following LST: Municipality ______________________________________________
County ______________________________________________
Social Security No.
Daytime Phone No.
Employee Name:
Street Address:
City/State/Zip:
Instructions: Check & complete where necessary, the item number below that pertains to your refund request. Item
numbers 1-4 below result in a refund of both municipal & school portions of the tax, where applicable. Item number
5 often results in a refund of only the municipal portion of an LST. Refer to SCHEDULE I on the back of this form
to determine the amount of any possible refund for the Low-Income Exemption. In EVERY case below you must
submit proof of payment of ALL LST that you claim to have paid. Examples of proof of payments are: employer
issued W-2 Forms or payroll check stubs clearly identifying the deduction and the period thereof, and/or a receipted
LST-3 Form (Personal Billing for LST) or cancelled check making personal payment.
1. ___
MULTIPLE CONCURRENT OCCUPATIONS: Complete a refund request form (i.e., this form) for each different
Attach documents to verify, by the concurrent
concurrent period for which you are claiming a multiple payment.
period, LST amounts paid, earnings and/or net profits, and your principle occupation for such period.
Complete all the information below, listing your principle employer in Row “A.”
This refund request is for the concurrent period of: (begin date) ____________ through (end date) ____________
Date began
Earnings
LST payment
work in
during
amount for
LST payment
Employer name or “SELF” if
concurrent
concurrent
Taxing jurisdiction(s) for
concurrent
amount for
paid personally
period
period
whom LST was paid
period
entire tax year
A.
$
$
$
B.
$
$
$
C.
$
$
$
D.
$
$
$
2. ___
ACTIVE DUTY MILITARY EXEMPTION: Attach a copy of your orders directing you to active duty status for the year of
the refund request.
3. ___
CLERGY EXEMPTION: I paid an LST based on my occupation as clergy. Enter the name, address, phone number &
contact person & title for the church, temple, etc., for which you are/were employed: ________________________________
____________________________________________________________________________________________________
4. ___
MILITARY DISABILITY EXEMPTION: Please attach copy of your discharge orders and a statement from the United
States Veterans Administrator documenting your disability. Only 100% permanent disabilities are recognized for this
exemption.
5. ___
LOW-INCOME EXEMPTION (Refer to SCHEDULE I on the back of this form to determine appropriate entries for the
blanks below): Important Note: No “Low-Income Exemption” refunds will be processed until after the end of the tax
year.
My total earned income and net profits from all sources within the municipality of _____________________________ was
less than $_________ (Column C). I therefore qualify for a refund of $_________ (lesser of actual LST paid or Column B,
less amount in Column E) reducing my LST liability to $_________ (Column E).
I DECLARE UNDER PENALTY OF LAW THAT ALL THE INFORMATION STATED ON AND SUBMITTED WITH
THIS FORM IS TRUE, CORRECT AND COMPLETE:
Taxpayer Signature: __________________________________________ Date: ______________