Form Lst - Application For Exemption From Local Services Tax

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TAX YEAR ________
DATE FILED ____________
WILKINS LOCAL SERVICES TAX OFFICE
2700 MONROEVILLE BLVD. MONROEVILLE, PA 15146-2388
MONTAX@MONROEVILLE.PA.US
412 856 3333
LOCAL SERVICES TAX – EXEMPTION CERTIFICATE
APPLICATION FOR EXEMPTION FROM LOCAL SERVICES TAX
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.
This application for exemption from the Local Services Tax must be signed and dated.
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.
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.
C:\data\Monroeville\tax\forms\Wilk_LST\LST-Exemption Form.doc
9/17/2015

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