Local Service Tax - Exemption Certificate - City Of Pittsburgh - 2013 Page 2
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2EMPLOYMENT INFORMATION: List all places of employment for the applicable tax year. Please
list your PRIMARY EMPLOYER under #1 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
Employer Phone
Start Date
End Date
Status FT or PT
Gross Earnings
4.
5.
6.
Employer Name
Address
Address 2
City, State & Zip
Municipality
Employer Phone
Start Date
End Date
Status FT or PT
Gross Earnings
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