"Application for Refund From Local Services Tax" - Pennsylvania

Application for Refund From Local Services Tax is a legal document that was released by the Berkheimer Tax Administrator - a government authority operating within Pennsylvania.

Form Details:

  • Released on October 1, 2007;
  • The latest edition currently provided by the Berkheimer Tax Administrator;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Berkheimer Tax Administrator.

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LOCAL SERVICES TAX – REFUND APPLICATION
___________________________________________
Tax Year
APPLICATION FOR REFUND FROM LOCAL SERVICES TAX
 A copy of this application for a refund of the Local Services Tax (LST), and all necessary supporting
documents, must be completed and presented to the tax office charged with collecting the Local Services
Tax.
 This application for a refund of the Local Services Tax must be signed and dated.
No refund will be approved until proper documents have been received
.
Name: _____________________________________
Soc Sec #: ____________________________________
Address: ___________________________________
Phone #: _____________________________________
City/State: _________________________________ Zip: _________________________________________
REASON FOR REFUND – CHECK ALL THAT APPLY
1. __________
I overpaid by more than $1.
2. __________
I had the tax withheld when it should have been exempted.
3. __________
MULTIPLE EMPLOYERS: Please attach a copy of a current pay statement from your
principal employer that shows the name of the employer, the length of the payroll period and the amount of
Local Services Tax withheld. Please list all employers on the reverse side of this form.
4. __________
TOTAL EARNED INCOME AND NET PROFITS FROM ALL SOURCES WITHIN
_____________________________________ (municipality or school district) WAS
LESS THAN $_____________: Please attach a copy of all of your last pay statements
from all employers within the political subdivision for the year prior to the fiscal year for
which you are requesting to be exempted from the Local Services Tax.
If you are self-employed, please attach a copy of your PA Schedule C, F, or RK-1 for the
year prior to the fiscal year for which you are requesting to receive a refund of the Local
Services Tax.
5. __________
ACTIVE DUTY MILITARY EXEMPTION: Please attach a copy of your orders
directing you to active duty status.
6. __________
MILITARY DISABILITY EXEMPTION: Please attach copy of your discharge orders
and a statement from the United States Veterans Administrator or its successor declaring your disability to be
a total one hundred percent permanent disability.
Tax Office: Berkheimer Tax Innovations
Address:
PO Box 25156
Phone #: (610) 588-0965
City/State: Lehigh Valley, PA
Zip: 18002
LOCAL SERVICES TAX – REFUND APPLICATION
___________________________________________
Tax Year
APPLICATION FOR REFUND FROM LOCAL SERVICES TAX
 A copy of this application for a refund of the Local Services Tax (LST), and all necessary supporting
documents, must be completed and presented to the tax office charged with collecting the Local Services
Tax.
 This application for a refund of the Local Services Tax must be signed and dated.
No refund will be approved until proper documents have been received
.
Name: _____________________________________
Soc Sec #: ____________________________________
Address: ___________________________________
Phone #: _____________________________________
City/State: _________________________________ Zip: _________________________________________
REASON FOR REFUND – CHECK ALL THAT APPLY
1. __________
I overpaid by more than $1.
2. __________
I had the tax withheld when it should have been exempted.
3. __________
MULTIPLE EMPLOYERS: Please attach a copy of a current pay statement from your
principal employer that shows the name of the employer, the length of the payroll period and the amount of
Local Services Tax withheld. Please list all employers on the reverse side of this form.
4. __________
TOTAL EARNED INCOME AND NET PROFITS FROM ALL SOURCES WITHIN
_____________________________________ (municipality or school district) WAS
LESS THAN $_____________: Please attach a copy of all of your last pay statements
from all employers within the political subdivision for the year prior to the fiscal year for
which you are requesting to be exempted from the Local Services Tax.
If you are self-employed, please attach a copy of your PA Schedule C, F, or RK-1 for the
year prior to the fiscal year for which you are requesting to receive a refund of the Local
Services Tax.
5. __________
ACTIVE DUTY MILITARY EXEMPTION: Please attach a copy of your orders
directing you to active duty status.
6. __________
MILITARY DISABILITY EXEMPTION: Please attach copy of your discharge orders
and a statement from the United States Veterans Administrator or its successor declaring your disability to be
a total one hundred percent permanent disability.
Tax Office: Berkheimer Tax Innovations
Address:
PO Box 25156
Phone #: (610) 588-0965
City/State: Lehigh Valley, PA
Zip: 18002
Employment 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.
1. PRIMARY EMPLOYER 2.
3.
Employer Name
Address
Address 2
City, State Zip
Municipality
Phone
Start Date
End Date
Status (FT or PT)
Gross Earnings
4.
5.
6.
Employer Name
Address
Address 2
City, State Zip
Municipality
Phone
Start Date
End Date
Status (FT or PT)
Gross Earnings
PLEASE NOTE:
All information received by the Tax Collector is considered to be CONFIDENTIAL and is only used for
official purposes relating to the collection, administration and enforcement of the LOCAL SERVICES
TAX.
I DECLARE UNDER PENALTY OF LAW THAT THE INFORMATION STATED ON AND
ATTACHED TO THIS FORM IS TRUE AND CORRECT:
SIGNATURE: _________________________________________________ DATE: ____________________
LST Refund 10-07
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