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  

LST Refund 10-07 

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