DUE BY:                                        ____ EMPLOYER QUARTERLY LOCAL SERVICE TAX (LST) WITHHOLDING RETURN 
   1ST QTR - APRIL 30, ____                                                           CAPITAL TAX COLLECTION BUREAU 
   2ND QTR - JULY 31, ____                                                            Combined FORM LST-2 and LST-4
     3RD QTR - OCT 31, ____                                                       Make additional copies of this blank form or visit our website at
     4TH QTR - JAN 31, ____                                                www.captax.com for a blank form for additional submissions
                                      You are entitled to receive a written explanation of your rights with regards to the audit, appeal, enforcement, refund and collection of local taxes 
                                                                                  withheld by contacting Capital Tax Collection Bureau.
               Remit Form(s) and Payment to:  Capital Tax Collection Bureau, 8391 Spring Rd Ste #3 New Bloomfield PA 17068              Phone Number: 717-957-7281
FEDERAL EIN                                                            Account Number               WORKSITE PSD CODE   YEAR                        QUARTER

EMPLOYER BUSINESS NAME (Use Federal ID Name)

EMPLOYER MAIN BUSINESS LOCATION - STREET ADDRESS (No  PO Box, RD, or RR)

SECOND LINE OF ADDRESS

CITY                                                                                                STATE                              ZIP

BUSINESS PHONE NUMBER                                                             BUSINESS FAX NUMBER

WORKSITE ADDRESS IF DIFFERENT THAN ABOVE

SECOND LINE OF ADDRESS

CITY                                                                                                STATE                              ZIP

MUNICIPAL TAXING AUTHORITY IN WHICH WORKSITE IS LOCATED                                                   COUNTY

SCHOOL DISTRICT

1.  Total number of employees reported here in
2.  Total LST Tax Withheld
3.  Discount (refer to the rate table for the discount rate of the PSD you're for reporting.)             RATE:
4.  Net amount due – Enclosed (Line 2 minus Line 3)
5.  Penalty (0.05% flat rate) (Multiply Line 4 by penalty rate when applicable) 
6.  Interest (0.005% per month) (Multiply Interest rate by Line 4 then by number of months return is late) 
7.  Processing Fees
8.  Total (Add Line 4, Line 5, Line 6 & Line 7)
                         I (WE) DECLARE, UNDER PENALTY OF LAW, THAT THE INFORMATION CONTAINED HEREIN IS TRUE AND CORRECT TO THE BEST OF MY (OUR) KNOWLEDGE.
                         PRIMARY CONTACT INDIVIDUAL (First Name, Last Name)                                                            TITLE

                         PRIMARY CONTACT PHONE NUMBER                                                     PRIMARY CONTACT EMAIL ADDRESS

                                             SIGNATURE OF PRIMARY CONTACT INDIVIDUAL                                                   DATE (MM/DD/YYYY)

                                                                                      EXEMPT              COMPLETE LST                              SCHOOL LST 
EMPLOYEE'S SOCIAL                            EMPLOYEE'S NAME & ADDRESS                (EXEMPTION      (MUNICIPALITY AND SCHOOL)             (ONLY SCHOOL PORTION)
SECURITY NUMBER                                                                       FORM MUST  BE AMOUNT WITHHELD  THIS QUARTER           AMOUNT WITHHELD  THIS QUARTER
                                                                                      ATTACHED)                                             (SEE INSTRUCTIONS)  

                                                                                      -             $                                  $

                                                                                      -             $                                  $

                                                                                      -             $                                  $
FIRST PAGE TOTALS ……………………………………………………………………………….……………..….                                          $                                  $
FIRST PAGE TOTAL LST WITHHELD THIS QUARTER…………………………………...………….…..… $
ThereMake checkswill be apayable$35.00to: feeCTCBfor returned payments and checks.    TOTAL AMOUNT LST ENCLOSED …………..…                $