File completed form
   with your employer
                              LocaL ServiceS Tax
   Form LST21E2.1                        xempTion appLicaTion                        PO Box 559 • Irwin PA 15642
                                        e

                                        File completed application with your employer
                                 do noT uSE ThiS Form To rEquEST a rEFund           
                                        Click here to download LST Refund Application

Name                                                           Tax Year

Address                                                        SSN

City/State                                                     Phone

Zip

                              Reason for Exemption (check all that apply)

           Multiple Employers           List all employers on page 2 of this form
             Provide employer information on reverse side. Attach a copy of your final 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 copy(s) of final pay statement(s) from employer(s). You may also attach a copy of your prior year W-2(s).  

           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 

                                        inSTrucTionS for    empLoyerS
   1. If the employee qualifies for this exemption, do not withhold the Local Services Tax from payroll.
   2. Employees earning less than $12,000 in earned income from all sources are exempt from the municipal portion of 
      the Local Services Tax when the tax rate exceeds $10.
   3. The school district in which your business is located may or may not levy the Local Services Tax. If it does, the 
      income exemption may differ from the municipal exemption.
   4. Contact the Tax Officer at www.KeystoneCollects.com for additional information regarding the Local Services Tax. 

File completed form
with your employer
                      LocaL ServiceS Tax
Form LST21E2.1        xempTion appLicaTion – page 2                                 PO Box 559 • Irwin PA 15642
                      e

                                                         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 your employer
                      do noT uSE ThiS Form To rEquEST a rEFund            
                                   Click here to download LST Refund 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.