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Exemption Certificate From Local Services Tax (Lst) - Pennsylvania Capital Tax Collection Bureau - 2015 Page 2

CONTERMINOUS EMPLOYER INFORMATION – List all places of employment for the applicable tax year. List your PRIMARY EMPLOYER under # 1

below and your secondary employers under the other columns. If self-employed, enter SELF in the “Employer Name” Row. If you need to list more

than 3 employers use an additional Exemption Form & change the numbers of the employers listed under this conterminous employer information

table to 4, 5, etc.

1. Primary Employer

Employer Name

Street Address 1

Street Address 2

City, State & Zip Code

Municipality

Phone

Start Date

Status (Full or Part Time)

Expected earnings for tax year

_________

CAPTIAL TAX COLLECTION BUREAU OFFICES

HARRISBURG OFFICE

HUNTINGDON COUNTY OFFICE

PERRY COUNTY OFFICE

SOMERSET COUNTY OFFICE

2301 N 3RD ST

18839 SANDY RIDGE STATION, SUITE 2

2971 COLD STORAGE RD

PO BOX 146

HARRISBURG PA 17110-1893

ORBISONIA PA 17243

NEW BLOOMFIELD PA 17068

SOMERSET PA 15501

Phone: (717) 234-3217

Phone: 814-447-3111

Phone: 717-582-3001

Phone: (814) 701-2475

Fax:

(717) 234-2962

Fax: 814-447-3113

Fax: 717-582-3002

Fax: (814) 701-2318

OPEN TUESDAYS ONLY

Exemption Certificate From Local Services Tax (Lst) - Pennsylvania Capital Tax Collection Bureau - 2015 Page 2