Form Lst - Application For Exemption From Local Services Tax - 2016 Page 2
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1
2Employment 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
Slippery Rock University
Address
1 Morrow Way
Address 2
City, State Zip
Slippery Rock, PA 16057
Municipality
Slippery Rock Borough
Phone
724-738-2069
Start Date
End Date
Currently Employed
Status (FT or PT)
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 Exemption 10-07
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Parent category: Business