LOCAL SERVICES TAX – EXEMPTION CERTIFICATE

___________________________________________

Tax Year

APPLICATION FOR EXEMPTION FROM LOCAL SERVICES TAX

Ø 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 for the municipality or school district in which you are primarily employed.

Ø This application for exemption from the Local Services Tax must be signed and dated.

Ø No exemption will be approved until proper documentation has been received.

Name:	________________________________	Soc Sec #:	________________________________
Address:	________________________________	Phone #:	________________________________
City/State:	________________________________	Zip:	________________________________

REASON FOR EXEMPTION

1. __________ 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.

2. __________ 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.

3. __________ 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.

4. __________ 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: __________________________________ Phone #: _____________________________________

City/State: _________________________________ 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 combined 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 to $11,999.

3. Contact the tax office where your business worksites are located to obtain this information.

LST Exemption 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. PRIMARY EMPLOYER	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 Exemption 10-07