Mail to:
Keystone Collections Group
PO Box 559 • Irwin PA 15642
                              LocaL ServiceS Tax
   Form LST22r2.1                            efund appLicaTion
                                           r

                                         File completed application with Tax Officer 
                   do noT FiLe ThiS Form wiTh your earned income Tax reTurn              
                                        Click here to download LST Exemption Application

Name                                                         Tax Year

Address                                                      SSN

City/State                                                   Phone

Zip

                               Reason for Refund (check all that apply)

           Overpaid by more than $1

           Exempt but withheld in error

           Multiple Employers            List all employers on page 2 of this form
             Provide employer information on reverse side. Attach a copy of your current pay statement from each 
             employer. Each statement must show:
             ¾  Name of employer
             ¾  Length of payroll period
             ¾  Amount of Local Services Tax withheld 
             ¾  Total earnings
                   Notify employers of a change in principal place of employment within two weeks of the change

           Income Exemption
             Annual income
           Income exemption for Local Services Tax is $12,000 or less from all sources of earned income and net profits, when the LST tax rate exceeds 
           $10 per year. Attach copies of current or final pay statement(s) from employer(s). You may also attach a copy of your prior year W-2.  

           Military (Active Duty or Disabled)
           ¾ If you are Active-Duty military, attach copy of orders. Annual training is not eligible for exemption from LST.
           ¾ If you are disabled, attach a copy of your military discharge orders and a statement from the Department of Veterans’ Affairs documenting 
             your qualifying disability.

           Clergy 

           for uSe by ndividuaL    i      TaxpayerS onLy  • empLoyerS do noT SubmiT ThiS form:                               

   Contact the Tax Officer at www.KeystoneCollects.com for additional information regarding the Local Services Tax. 

          Mail to:
Keystone Collections Group
PO Box 559 • Irwin PA 15642    LocaL ServiceS Tax
Form LST22r2.1                 refund appLicaTion – page 2

                                                         empLoymenT informaTion 

1.  List all places of employment for the applicable tax year.
2.  List your PRIMARY EMPLOYER in column 1 (below) and any secondary employers in the other columns.
3.  If you are self-employed, write SELF in the Employer Name field. 

                            1.  Primary Employer                     2.           3.
Employer Name
Address
Address 2
City/State/Zip
Municipality
Employer Phone
Start Date
End Date
Gross Earnings

                            4.                                       5.           6.
Employer Name
Address
Address 2
City/State/Zip
Municipality
Employer Phone
Start Date
End Date
Gross Earnings

                                 File completed application with Tax Officer 
                  do noT FiLe ThiS Form wiTh your earned income Tax reTurn          
                               Click here to download LST Exemption Application

I declare under penalty of law that the information stated here and submitted with this form is true and correct. I understand and 
acknowledge that the information I provide with this application is subject to verification and audit at any time. 

                  Signature of Applicant                                         Date

Information received by the Tax Collector is considered CONFIDENTIAL and for official purposes relating to the collection, administration and enforcement of the tax. 
            Additional information may be required (including a copy of applicant’s state income tax return) to clarify, verify or support this application.