LOCAL SERVICES TAX - REFUND APPLICATION  Tax Year  APPLICATION FOR REFUND FROM LOCAL SERVICESTAX  Acopy ofthis application for a refund oft 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: Address: City/State:  Soc Sec #: Phone #: Zip:  REASON FOR REFUND - CHECK ALL' THAT APPLY  1. 2. 3.  Ioverpaid by more than $1.  Ih had the tax withheld when it should have been exempted.  MULTIPLE EMPLOYERS: Please attach a copy ofa current pay statement from your principal employer that shows the name oft the employer, the length ofthe payroll period and the amount ofLocal Services Tax withheld. Please list all employers on the reverse TOTAL EARNED INCOME AND NET PROFITS FROM. ALL SOURCES WITHIN 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. Ifs you are self-employed, please attach a copy ofy your PA Schedule C, F, or RK-1 for the year prior to the fiscal year for which you are requesting to receive ai refund oft thel Local ACTIVE DUTY MILITARY EXEMPTION: Please attach a copy ofy your orders 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 ai total one hundred percent permanent disability.  side oft this form.  4.  (municipality or school district) WAS  LESS THANS  Please attach a copy ofall ofyour last pay statements  Services Tax.  5. 6.  directing you to active duty status.  Tax Office: Address: City/State: LST Refund 10-07  Phone #: Zip:    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. Ifself  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: TAX.  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  IDECLARE UNDER PENALTY OF LAWTHATTHE INFORMATION STATED ON AND  ATTACHED TO1 THIS FORM IS TRUE. AND CORRECT:  SIGNATURE: LST Refund 10-07  DATE: