LST-3 Local Services Tax Individual Return  
                                                                                                                                                *LSTQ3*

       PO BOX 25156
       LEHIGH VALLEY, PA 18002-5156

Name
Address
City
State
ZIP

                                                                            You are entitled to receive a written explanation of your rights with regard to the audit,
Enter Your Social Security Number:                                          appeal,  enforcement,  refund  and  collection  of  local  taxes  by  calling  Berkheimer  at
                                                                            610-599-3142  during the hours of 8:00 AM - 4:00 PM, Monday through Friday.  Or,
                                                                            you can visit our website at www.hab-inc.com.  If Berkheimer is not the appointed tax
                                                                            hearing officer for your taxing district, you must contact your taxing district about the
                                                                            proper procedures and forms necessary to file an appeal.

                                                                            The Local Services Tax is a local tax due from all individuals who are employed within the taxing jurisdiction printed below.
Payable to:  HAB-LST                                                        All Federal Employees and all Self-Reporting Individuals who perform services of any kind or engage in any occupation or
                                                                            professions within the stated Borough, Township, or School District are required to pay a Local Services Tax.
BERKHEIMER, PO BOX 25156, LEHIGH VALLEY, PA 18002-5156
                                                                            Please complete and return the LST-3 form below with your payment due. If remitting the annual tax amount due in full,
                                                                            please submit all returns with your payment at the time of filing. If for some reason you already paid the tax in another
                                                                            political subdivision, or at another place of employment, provide this office with proof of payment and we will adjust our
JURIS NO.JURIS NO.                                                          records accordingly. If your primary employment jurisdiction has the Local Services Tax, the tax is not to be deducted from
                                                                            the secondary place of employment.
QUARTER _____ YEAR ________

WORK LOCATION:
                                                                                                              Exemption Enclosed-no tax due  (check here)

                                                                                                              1. Tax Due                    ¸ 4 , ,                                      .
                                                                            2. Penalty (line 1  x  0.05   )if paid after due date               , ,                                      .
                                                                                                                                                ,
                                                                            3. Interest (line 1 x   0.005 ) per month after due date              ,                                      .
                           WEB 4.  Total Penalty & Interest (line 2 + line 3) 
                                                                                                                                                , ,                                      .
. Your cancelled check is sufficient proof of payment.  
. There will be a $29.00 cost for insufficient funds and returned payments. 5. Total of Check Enclosed (line 1 + line 4)                        ,,.
.  Make Checks payable to: HAB-LST                                          Make Checks payable to:           HAB-LST                           , ,                                      .