Local Services Tax – Refund Application

Form Overview

This document is a Local Services Tax (LST) Refund Application form, identified by the code "LST Refund 10-07" at the bottom of both pages. It is designed for residents to request a refund from their local tax office if they have overpaid or are eligible for an exemption.

Instructions and Requirements

The form outlines three critical rules for submission:

• Completeness: The application must be completed with all necessary supporting documents.
• Signature: It must be signed and dated by the applicant.
• Approval: No refund will be approved until proper documentation is received.

Applicants must provide their personal details, including Name, Address, City/State, Zip, Social Security Number, and Phone Number.

Reasons for Refund

Applicants must check the box corresponding to their reason for requesting a refund:

1. Overpayment: The applicant overpaid by more than $1.
2. Exemption Error: Tax was withheld when it should have been exempted.
3. Multiple Employers: The applicant worked for multiple employers. This requires attaching a current pay statement from the principal employer and listing all employers on the reverse side of the form.
4. Low Income Exemption: Total earned income and net profits from all sources within the municipality or school district were less than a specific dollar amount.
   • Requirements: Attach copies of the last pay statements from all employers within the political subdivision for the year prior to the fiscal year.
   • Self-Employed: Must attach a copy of PA Schedule C, F, or RK-1 for the year prior to the fiscal year.
5. Active Duty Military Exemption: Requires attaching a copy of orders directing the applicant to active duty status.
6. Military Disability Exemption: Requires attaching discharge orders and a statement from the United States Veterans Administrator declaring a total one hundred percent permanent disability.

Employment Information (Reverse Side)

The second page is dedicated to listing employment history for the applicable tax year.

• Primary Employer: Must be listed under column #1.
• Secondary Employers: Listed under columns 2–6.
• Self-Employed: Write "SELF" in the Employer Name column.

For each employer, the following details are required:

• Employer Name and Address (including Municipality)
• Phone Number
• Start Date and End Date
• Status (Full-Time or Part-Time)
• Gross Earnings

Declaration and Submission

The form concludes with a confidentiality note stating that all information is used only for official tax collection and enforcement purposes.

The applicant must sign and date the form under penalty of law, declaring that the information stated is true and correct. The bottom section provides space to list the specific Tax Office details (Address, City/State, Zip, Phone) where the application is being submitted.