Local Service Tax - Exemption Certificate - City Of Pittsburgh

CITY OF PITTSBURGH

2013 LOCAL SERVICE TAX – EXEMPTION CERTIFICATE

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.

This application for exemption from the Local Services Tax must be signed, dated, and given to each

employer.

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

: ______________________________

____________________

PRINT NAME

SOCIAL SECURITY #:

: ________________________________

#: ____________________________

ADDRESS

PHONE

: ________________________________________________________________

CITY – STATE – ZIP

REASON FOR EXEMPTION

_____ 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 THE CITY OF PITTSBURGH WILL BE LESS THAN $12,000:

Attach copies of your last

pay statements from all employers or copies of your W-2’s from all employers for the prior year. Also submit

copies to your employer(s).

If you are SELF-EMPLOYED, attach a copy of your PA Schedule C, F, or RK-1 for the prior year.

_____ACTIVE DUTY MILITARY EXEMPTION:

Attach a copy of your orders directing you to active duty

status. Annual training is not eligible for exemption. You are required to advise your employer and tax office

when you are discharged from active duty status

_____MILITARY DISABILITY EXEMPTION:

Attach a 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 taxpayer or tax collector to withhold the tax

Employer must retain Exemption Certificate

Tax Office:

LST Exemption Certificate, City of Pittsburgh, Department of Finance,

Address:

414 Grant Street Room 212

City, State & Zip:

Pittsburgh PA 15219

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.

SIGNATURE:_________________________________________________

DATE: __________________________

For additional information go to or call 412-255-2504.

Local Service Tax - Exemption Certificate - City Of Pittsburgh - 2013

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