LOCAL EARNED INCOME TAX RETURN                                                     THIS RETURN MUST BE FILED BY
                                                                                                                         APRIL 15.
             LANCASTER COUNTY TAX COLLECTION BUREAU                                                  Please Note: If you received a Tax Return it 
                   1845 William Penn Way Suite 1 • Lancaster, PA 17601-6713                          must be filed with the bureau. Failure to file 
                          Phone (717) 569-4521 • www.lctcb.org                                       will result in audit and/or prosecution.
                                                                                                                                                       FOR OFFICIAL USE ONLY
             A Taxpayer information                                                                                                                       TAX YEAR
             Taxpayer A  

             Taxpayer B                                                                                                                               Check all that apply:

             Address                                                                                                                                   Moved (Complete
                                                                                                                                                          Section B and Schedule P)
                                                                                                                                                       Extension Request
                                                                                                                                                       Amended Return
             City                                                 State                                                                               If you had no Earned Income
                                                                                                                                                      check reason:
             Zip Code                                                                                                                                   A B   Taxpayer
                                                                                                                                                            Disabled
                                     Please  Indicate: Single                                 Married, Filing Jointly  Married, Filing Separately       Deceased
             B COMPLETE THIS SECTION IF YOU MOVED DURING THE TAX YEAR. ACCOUNT FOR ALL 12 MONTHS.                                                           Homemaker
                                    Address                            From MM/DD/YYYY               To MM/DD/YYYY         Municipal Code (Table 1)         Unemployed
                                                                                                                                                            Student
                                                                                                                                                            Military
                                                                                                                                                            Retired
             C SELECT MUNICIPAL CODE FOR YOUR RESIDENCE ON                                           TAXPAYER A                                        TAXPAYER B
5005           12/31  FROM TABLE 1 (See Instructions): 
             D SOCIAL SECURITY NUMBER (Enter complete SS#)                                                                                   D

             1 W-2 EARNINGS                                                                                                0  0              1                             0  0
                                            Enclose Supporting W-2’s
             2 EMPLOYEE BUSINESS EXPENSE                                                                                   0  0              2                             0  0
                                            Enclose Pennsylvania form PA - UE
             3 OTHER TAXABLE EARNED INCOME                                                                                 0  0              3                             0  0
                                    DO NOT include interest, dividends or capital gains
             4 TOTAL TAXABLE EARNED INCOME                                                                                 0  0              4                             0  0
                          Line 1 minus Line 2 plus Line 3. If less than zero, enter zero
             5 NET PROFIT(S)                                                                                               0  0              5                             0  0
                         Enclose Schedules/Report S Corp. income on reverse side only
             6 NET LOSS(ES)                                                                                                0  0              6                             0  0
                         Enclose Schedules/Report S Corp. loss(es) on reverse side only
             7 TOTAL TAXABLE NET PROFIT(S)                                                                                 0  0              7                             0  0
                                    Line 5 minus Line 6. If less than zero, enter zero 
             8 TOTAL TAXABLE EARNED INCOME AND NET PROFIT                                                                  0  0              8                             0  0
                                                       Line 4 plus Line 7
             9 TAX LIABILITY Line 8 multiplied by decimal tax rate __________.                                             0  0                                            0  0
                                                       See instructions                                                                      9

10 TOTAL LOCAL INCOME TAX WITHHELD                                                                                         0  0              10                            0  0
                                            As indicated on enclosed W-2’s
11 ESTIMATED PAYMENTS and/or PRIOR YEAR CREDIT                                                                             0  0              11                            0  0
              APPLIED TO THIS TAX YEAR
12 CREDIT FOR TAXES                         Worksheet on Reverse Side                                                      0  0                                            0  0
                                                                                                                                             12
              PAID TO PHILADELPHIA and/or OTHER STATES
13 TOTAL CREDITS                                                                                                           0  0              13                            0  0
                                            Add Lines 10, 11, and 12
14 OVERPAYMENT/REFUND                                                                                                      0  0              14                            0  0
                                    Line 13 minus Line 9. If less than $2.00, enter zero
15 AMOUNT OF OVERPAYMENT TO                            Next Year  Spouse                                                   0  0                                            0  0
                                                                                                                                             15
              CREDIT TO NEXT YEAR/TRANSFER to/from SPOUSE
16 TAX BALANCE DUE                                                                                                         0  0              16                            0  0
             Line 9 minus Line 13, minus any credit from spouse. If less than $2.00, enter zero
17 PENALTY & FEES                                                                                                          0  0              17                            0  0
                                            Add 1% per month after April 15
18 INTEREST                                                                                                                0  0              18                            0  0
                                                       See instructions
19 TOTAL AMOUNT DUE                                                                                                        0  0              19                            0  0
                                            Add Lines 16, 17 and 18

20             I/we declare under penalties provided by law that this return and all accompanying schedules and statements have been examined by me/us.
               To the best of my/our knowledge and belief they are true, correct and complete.
                         Signature A                   Day Phone                                Date    Occupation                                  PAID PREPARER’S NAME
                                                                                                                                               (PLEASE PRINT) & TELEPHONE:
LCTEITGEN514             Signature B                   Day Phone                                Date    Occupation                              Signature          Day Phone

                                                                     SCHEDULE P
           COMPLETE ONLY IF YOU MOVED INTO OR OUT OF THE LCTCB JURISDICTION(S).    
                                                                     SECTION A
Taxpayer A                                     EMPLOYMENT WORKSHEET 
 EMPLOYER/SOURCE OF INCOME                                           DATES EMPLOYED                       LCTCB Portion                                                                                        Other Collector Portion
 Enclose a W-2 for each employer listed below.                       FROM             TO
 Report W-2 income only in this section.       MM/DD/YYYY                     MM/DD/YYYY       WAGES           TAX                                                                                             WAGES    TAX
1
2
3
                                                                                      TOTAL
                                                                                               Enter on Line 1 Enter on Line 10
Taxpayer B
 EMPLOYER/SOURCE OF INCOME                                           DATES EMPLOYED                       LCTCB Portion                                                                                        Other Collector Portion
 Enclose a W-2 for each employer listed below.                       FROM             TO
 Report W-2 income only in this section.       MM/DD/YYYY                     MM/DD/YYYY       WAGES           TAX                                                                                             WAGES    TAX
1
2
3
                                                                                      TOTAL
                                                                                               Enter on Line 1 Enter on Line 10
                                                                     SECTION B
                                               NET PROFIT(S) AND LOSS(ES) WORKSHEET
Report only the LCTCB portion of the income and/or loss on Line(s) 5 and Line(s) 6 of the tax return. 
                                                                                      LCTCB
 Enclose Net Profit(s)/Loss(es) –                                             Portion Of Profit(s) (Line 5)    Other Collector Portion Of Profit(s)
 Supporting Schedules             Profit       Loss                           And Loss(es) (Line 6)                            And Loss(es)  

                                                                     SECTION C
                                            OTHER TAXABLE EARNED INCOME WORKSHEET 
Report only the LCTCB portion of the income on Line 3 of the tax return. 
           Other Taxable Income
Enclose 1099 or written explanation of income for each entry. Do not
 include income from interest, dividends or PA Unemployment                                                             Other Collector Portion Of
           Compensation Benefits                                          LCTCB Portion Of The Income (Line 3)                 The Income  

                                                                          S-Corp
                                                                     REPORTING SCHEDULE
For audit purposes only. Do not include in calculating total taxable income.  
                        S-Corp
           Enclose – Supporting Schedules                                               Profit                                                                                                                 Loss 

           NON RECIPROCAL STATE/PHILADELPHIA CREDIT WORKSHEET
 COMPLETE ONLY IF EARNED INCOME WAS RECEIVED FROM A NON-RECIPROCAL STATE OR THE CITY OF PHILADELPHIA   
1.  GROSS INCOME taxed by other state as shown on other state’s return or for Philadelphia credit as shown
    on W-2 or as reported to the City of Philadelphia (Required: attach copy of out-of-state filing) .................................................................                                          
2.  Maximum Tax Rate allowed as Credit is 1.00%  .........................................................................................................................................X                         .01 
3.  Tax Credit (Line 1 x Line 2)  ...........................................................................................................................................................................   
4.  Tax liability paid to other state or Philadelphia ..............................................................................................................................................            
5.  PHILADELPHIA CREDIT Lesser of Lines 3 or 4 ......................................................................................................................................                           
6.  OUT-OF-STATE CREDIT Line 1 x PA Income Tax Rate - Enclose copy of Out of State Return ...........................................................                                                           
7.  Line 4 Minus Line 6. If Line 6 is more than line 4, Enter Zero - No Credit Allowed
    Enter lesser amount from Line 3 or 7 on Line 12 ...........................................................................................................................................                 
           If more space is needed for Sections A, B, C or S-Corp, you may attach an additional sheet of paper. 
                                                                                                                                                                                                                        LCTCB 2014