Local Services Tax Employee Listing Sheet
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1LOCAL SERVICES TAX
EMPLOYEE LISTING SHEET
__________________________________________________________________________________________________________
EMPLOYER’S NAME AND ADDRESS OF PRINCIPAL PLACE OF BUSINESS:
MUNICIPALITY NAME:
_____________________________
PSD CODE (Political Subdivision):
__ __ __ __ __ __
FEIN:
______________
QUARTER:__________ QUARTER ENDING DATE:__________
Employee’s Social
Name and Address of Employee
Tax Withheld
Security Number
st
Page Total:
Qtr - Ends 03/31 - Due 04/30
1
nd
2
Qtr - Ends 06/30 - Due 07/31
Quarter Total:
rd
3
Qtr - Ends 09/30 - Due 10/31
th
4
Qtr - Ends 12/31 - Due 01/31
PLEASE MAKE CHECK PAYABLE AND REMIT TO:
Keystone Collections Group
546 Wendel Road
Irwin, PA 15642
Phone: (724) 978-0300
Fax: (724) 978-0339
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