DUE BY:                  ____ EMPLOYER QUARTERLY LOCAL SERVICE TAX (LST) WITHHOLDING RETURN 
1ST QTR - APRIL 30, ____                      CAPITAL TAX COLLECTION BUREAU 
2ND QTR - JULY  31, ____                                   FORM LST-2 
3RD QTR - OCT   31, ____ (TO BE USED IN ADDITION TO THE COMBINED FORM LST-2 AND LST-4 WHEN NEEDED.)
4TH QTR - JAN   31, ____ 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

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

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PAGE TOTALS ………………………………………………………………………………………………….$                                      $
PAGE TOTAL LST WITHHELD THIS QUARTER………………………………………..……………$