85813.3 Short Form
3/25/08
LANCASTER COUNTY TAX COLLECTION BUREAU
MIDDLETOWN AREA TAX COLLECTION BUREAU
1845 William Penn Way, Lancaster, PA 17601 717/569-4521
LOCAL SERVICES TAX EMPLOYEE WITHHOLDING EXEMPTION CERTIFICATE
(for use where the Bureau collects LST)
________________________________
Tax Year
This application for exemption from withholding of local services tax and supporting documents must be completed, signed,
and presented to employer AND the Bureau. No exemption is effective until proper documentation has been received and
approved by the employer.
Employee Name: Soc. Sec. #:
Address: Phone #:
City/State: Zip:
REASON FOR EXEMPTION
1. ____ MULTIPLE EMPLOYERS/MULTIPLE PER PAYROLL TAX: I am exempt from withholding based on
paying a local services tax pro rata per payroll to another, principal employer. I will notify employers of a change
in principal place of employment within 2 weeks of the change. (Attach a copy of a current pay statement from
principal employer that shows the name of the employer, the length of the payroll period, and the amount of local
services tax withheld. List all employers at the bottom of this form.)
2. ____ LOW INCOME EXEMPTION - $12,000: I expect my total earned income and net profits from all sources will
be less than $12,000 within _________________________________ (specify municipality that imposes the tax.)
(Attach copies of last pay statements or W-2 for the prior year.)
3. ____ ACTIVE DUTY MILITARY EXEMPTION: I am exempt from tax because my occupation within the
jurisdiction imposing the tax is active military duty. (Attach a copy of orders directing active duty status. Annual
training is not eligible for exemption.)
4. ____ MILITARY DISABILITY EXEMPTION: I am exempt from tax based on military disability. (Attach a copy
of discharge orders and a statement from the U.S. Veterans Administrator documenting disability. Only 100%
permanent disabilities are recognized for this exemption.)
5. ____ RELIGIOUS CLERGY EXEMPTION: My sole occupation within the jurisdiction imposing the tax is
performing services as a member of the religious clergy.
6. ____ PRIOR PAYMENT: I have previously paid the full amount of the tax to the municipality and/or school district
imposing the local services tax, or have previously paid for this tax year $52 as a local services tax based on an
occupation within Pennsylvania. (Attach evidence substantiating payment.)
NOTE TO EMPLOYER: Once you receive a properly completed certificate, you should promptly send a copy to the
Bureau. Unless you have reason to believe the certificate is inaccurate, you should not withhold the local services tax
for the portion of the calendar year for which the certificate applies, until otherwise instructed by the employee or
Bureau or until you have reason to conclude the tax withholding exemption no longer applies.
1. PRIMARY EMPLOYER 2. SECOND EMPLOYER 3. THIRD EMPLOYER
