LST Exemption 10-07
LOCAL SERVICES TAX – EXEMPTION CERTIFICATE
___________________________________________
Tax Year
APPLICATION FOR EXEMPTION FROM LOCAL SERVICES TAX
¾ A copy of this application for exemption from the Local Services Tax (LST), and all necessary supporting
documents,
must be completed and presented to your employer AND to the political subdivision levying the Local Services Tax
where you are principally employed.
¾ This application for exemption from the Local Services Tax must be signed and dated.
¾ No exemption will be approved until proper documentation has been received.
Name:_____________________________________
Address:___________________________________
City/State:
___________________________________________
Soc
Sec#: ____________________________________
Phone #: _____________________________________
Zip:
_________________________________________
REASON FOR EXEMPTION
1. _
_________
2. __________
3. _________
4. _________
MULTIPLE EMPLOYERS: 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. List all employers on the reverse side of this form. You must notify your
other employers of a change in principal place of employment within two weeks of the
change.
EXPECTED TOTAL EARNED INCOME AND NET PROFITS FROM ALL SOURCES WITHIN
_____________________________________________ (municipality or school district) WILL BE
LESS THAN $___________: Attach copies of your last pay statements or your W-2 for the year
prior.
If you are self-employed, please attach a copy of your PA Schedule C, F, or RK-1 for the prior
year.
ACTIVE DUTY MILITARY EXEMPTION: Please attach a copy of your orders directing you to
active duty status. Annual training is not eligible for exemption. You are required to advise the tax
office when you are discharged from active duty status.
MILITARY DISABILITY EXEMPTION: Please attach copy of your discharge orders and a
statement from the United States Veterans Administrator documenting your disability. Only 100%
permanent disabilities are recognized for this exemption.
EMPLOYER: Once you receive this Exemption Certificate, you shall not withhold the Local Services Tax for the
portion of the calendar year for which this certificate applies, unless you are otherwise notified or instructed by
the tax collector to withhold the tax.
Tax
Office:
___________________________________________
Address:
_____________________________________________
City/State:
___________________________________________
Phone #:___________________________________
Zip: _______________________________________
IMPORTANT NOTE TO EMPLOYERS
1. The municipality is required by law to exempt
from the LST employees whose earned income from all sources
(employers and self-employment) in their municipality is less than $12,000 when the levied rate exceeds
$10.00.
2. The school district for the municipality in which your worksite(s) is located may or may not levy an LST. If it
does, the income exemption provided may differ from the municipality and can be anywhere from $0 to
$11,999.
3. Contact the tax office where your business worksites are located to obtain this information.
HR 11/1/15
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 enforce
ment 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: ____________________
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