Exemption Certificate From Local Services Tax (Lst) - Pennsylvania Capital Tax Collection Bureau - 2015

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2015 EXEMPTION CERTIFICATE FROM LOCAL SERVICES TAX (LST)
Only for use with Taxing Jurisdictions who’s LST is collected by the Capital Tax Collection Bureau (CTCB)
(12/12/14 version)
I am requesting an exemption from the following LST:
Municipality _________________________________________
County _____________________________________________
If you’re requesting an exemption from the LST for an occupation thru an employer, YOU must file this completed application
and any required attachments with YOUR EMPLOYER.
If you’re requesting an exemption from the LST for an occupation thru self-employment, or thru an employer that is not
required to withhold the LST, YOU must file this completed application and any required attachments CTCB.
This application for exemption from the LST must be signed and dated by the taxpayer at the bottom of this page.
Social Security No.
Phone No.
IF EMPLOYED THRU AN EMPLOYER:
Employee Name:
Employer No.
Street Address:
Employer Name:
City/State/Zip:
Store No./Location:
Item numbers 1-4 below result in total exemption.
Item number 5 only results in a partial exemption.
o Refer to the 2015 LST Rate Table to determine the amount of any exemption for Low-Income.
REASON FOR EXEMPTION
1. ____ MULTIPLE CONCURRENT OCCUPATIONS (for credit for LST paid on prior occupations in this tax year use Form LST-
Credit): If your principal occupation is thru an employer that is withholding the LST, 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 your occupations on the reverse side of this form in SCHEDULE III.
If your principal occupation is thru self-employment or an employer that is not required to withhold the LST, attach a
copy of your tax receipt verifying payment of the current year LST to the taxing jurisdiction(s) of the location of your
self-employment & list all your occupations on the reverse side of this form in SECTION III. If your principal
occupation changes during the tax year, you are required to notify any non-principal employers of such within two
weeks of the change.
2. ____ ACTIVE DUTY MILITARY EXEMPTION:
Attach a copy of your orders directing you to active duty status for the year of the exemption request.
3. ____ CLERGY EXEMPTION: I paid an LST based on my occupation as clergy.
Enter the name, address, phone number & contact person & title for the church, temple, etc., for which you are/were
employed:_______________________________________________________________________________________________
4. ____ MILITARY DISABILITY EXEMPTION: Only 100% permanent disabilities are recognized for this exemption.
Please attach copy of your discharge orders and a statement from the United States Veterans Administrator documenting your
disability.
5. ____ LOW-INCOME EXEMPTION
(Refer to 2015 LST Rate Table to determine appropriate entries for the blanks below):
I affirm that I reasonably expect my total earned income and net profits from all sources within the municipality of
_____________________________ to be less than $_________ (Column C). I therefore qualify for an exemption of $_________
(Column D) reducing my employer’s withholding responsibility to $_________ (Column E). I will notify this employer immediately
should my 2015 earned income and net profits earned in this municipality equal or exceed $12,000 during this tax year. Attach
any immediate prior year copies of your last pay statements or your W-2s, and any PA Schedule C, F, or RK-1 if self-employed, for
occupations in the taxing jurisdiction(s) for which you’re requesting this exemption.
EMPLOYER: If the exemption requested is for reason Number 5 above and there is a $5.00 school district LST, the $5.00 must be remitted along
with this exemption form. The employer must forward a copy of the Exemption form (no attachments & only the front of the form unless for
Exemption # 1 in which case a copy of the back must be also be forwarded) to CTCB and retain the originals of all exemption forms & attachments
for 3 years. Once an employer receives this completed and signed Exemption Certificate along with its required attachments it must not withhold
the LST. However, you must begin or reinstate withholding if notified by either the employee or CTCB that the exemption is invalid, or in the case of
a low income exemption, upon payment to the employee of earned income within the taxing jurisdiction in an amount equal to or in excess of
$12,000 in the tax year. Note that where an exemption is found to be invalid, an employer is required to do “catch-up” withholding on the
employee, which consists of withholding the regular payroll period pro-rated amount, plus an amount equal to all the withholding missed due to the
invalid exemption.
I DECLARE UNDER PENALTY OF LAW THAT ALL THE INFORMATION STATED ON AND SUBMITTED WITH THIS FORM IS TRUE, CORRECT AND COMPLETE:
Taxpayer Signature: __________________________________________
Date: ______________

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