Emergency & Municipal Services Tax (Emst) Form - Lctcb printable pdf download

LANCASTER COUNTY TAX COLLECTION BUREAU

1845 William Penn Way, Lancaster, PA 17601

Telephone: (717) 569-4521

EMERGENCY & MUNICIPAL SERVICES TAX (EMST)

REFUND REQUEST FOR _____________

(Enter Tax Year)

INSTRUCTIONS: Complete the information requested below in its entirety and remit this form, along with

any additional documentation that may be required, to the address listed above. Refunds will only be granted

after all information is verified and the bureau has received the withheld tax from your employer(s).

IMPORTANT NOTE: Requests received without the required supporting documents or incomplete

information will be denied without further notification.

Taxpayer Information:

(please print neatly or type)

Name _________________________________________________ Soc. Sec. No. ________/______/________

Address __________________________________________________________________________________

(Street)

_____________________________________________

___________

________________

(City)

(State)

(Zip)

Telephone No. _________________________________________

Employer Information:

My primary employer for the year was _______________________________________________ and my work

(Name of Employer)

location was in _____________________________________________.

(Name of Municipality)

EMST was withheld by two or more employers and exceeds the $52 maximum set by law.

(Enclose copies of the payroll stubs showing the EMST withheld. Employers name and address must be included if not

printed on the stubs.)

EMST was withheld, but my earnings did not exceed the exemption amount for the municipality.

(Enclose a copy of the payroll stub showing the EMST withheld, along with a copy of your Federal 1040 tax return and W-2

forms, for the tax year in which the EMST was withheld.)

Duplicate EMST withheld by the same employer.

(Enclose copies of payroll stubs.)

***Employer and Municipality where EMST was paid that you are requesting to be refunded.***

Employer(s) Name: _______________________________________________________________________

Municipality(s): __________________________________________________________________________

I DECLARE UNDER PENALTY OF LAW THAT THE INFORMATION STATED ABOVE IS TRUE,

CORRECT, AND COMPLETE, TO THE BEST OF MY KNOWLEDGE.

______________________________________________________

_______________________________

(Signature)

(Date)

FOR BUREAU USE ONLY

$______________

______/______/______

(Re fund Amt)

(Date)

Rev. Feb, 2007

Emergency & Municipal Services Tax (Emst) Form - Lctcb

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