LS-3  2019                     LOCAL SERVICES TAX 

      CFD                      PERSONAL RETURN – EMPLOYEE ONLY 
                               CITY OF PITTSBURGH   
 FOR PROPER CREDIT                                                                                                                                                                               Rev 09/18    
  SOCIAL SECURITY NUMBER MUST BE ENTERED IN BOX BELOW 
                                                               Amended Return (  )     Amended Return (  )                                 Tax Return No Longer Needed (  )      Tax Return No Longer Needed (  ) 
            CITY ID             SOCIAL SECURITY #                 
                                                                 SIGNATURE _____________________________________________ 
                                                                SIGNATURE _____________________________________________ 
                TAX PERIOD             QUARTER                   TITLE _____________________  DATE _______________________ 
                                                                TITLE _____________________  DATE _______________________ 
                                                                PHONE _________________________________________________ 
            Due on or before                                   PHONE            _________________________________________________ 
                                                                E-MAIL ADDRESS  ________________________________________ 
                                                               E-MAIL          ADDRESS                               ________________________________________ 
                                                                 PREPARER’S NAME  ______________________________________ 
                                                               PREPARER’S                                              ______________________________________                                                                                                                                       NAME  
                                                               PREPARER’S                                                   ______________________________________                                                                                                                                  PHONE 
                                                               IPREPARER’S hereby certify, swear and aver that all______________________________________statements herein are true and correct to the best of my knowledge and                                                                      PHONE 
                                                               I hereby certify, swear and aver that all statements herein are true and correct to the best of my knowledge and belief, being duly apprised of my duty under the law to submit honest and complete information or be subject to the 
                                                               belief,penaltiesbeingprovidedduly apprisedby law. of my duty under the law to submit honest and complete information or be subject to the 
                                                               penalties provided by law.                                                     
                                                                               OMISSION OF THE ABOVE APPLICABLE INFORMATION OMISSION OF THE ABOVE APPLICABLE INFORMATION 
                                                                                                 CONSTITUTESCONSTITUES ANANINCOMPLETEINCOMPLETERETURNRETURN               
                                                                                                                                              
  Make name/address corrections above                           
  USE BLACK INK ONLY ON THIS FORM 
             LOCAL SERVICES TAX IS $52.00 PER YEAR - $13.00 PER QUARTER 
                                                                                                                                                       
   1. LOCAL SERVICES TAX  

   2.  INTEREST AND PENALTY  PER MONTH 1.5% TOTAL (If applicable) 
         Interest per month 1% (0.01)  Penalty per month 0.5% (0.005)  
                                                                                                                                                      
   3.  TOTAL PAYMENT – Add lines 1 & 2 
                                                                                                                                                                                                 
   Make check payable to: TREASURER, CITY OF PITTSBURGH – DO NOT SEND CASH 
   Mail to:  CITY TREASURER LS-3 – 414 GRANT ST – PITTSBURGH PA 15219-2476 
   A $30.00 fee will be assessed for any check returned from the bank for any reason. 
  If you are employed within the City of Pittsburgh and your employer is NOT required or WILL NOT                                              withhold the Local Services 
  Tax, and you expect to make over $12,000 in the City of Pittsburgh this year, you are required to pay the tax yourself using this 
  form.  Failure to file will result in the imposition of a penalty and interest charge. 
   
  You should pay $13 per quarter for a total of $52.  First quarter, January, February & March return due April 30.  Second 
  Quarter, April, May & June return due July 31.  Third quarter, July, August & September return due October 31.  Fourth 
  quarter, October, November & December return due January 31. 
   
  Local Services Tax is $52.00 per person, per year, payable quarterly.  Pennsylvania law limits total payment by one person to a 
  maximum of $52.00 per year regardless of the number of employers in a year.  For information call 412-255-2510. 
   
  IF THIS FORM IS NO LONGER NEEDED, PLEASE COMPLETE THE FOLLOWING 
   
  A.     My employer is deducting the tax.   
 
         EMPLOYER_______________________________PAYROLL CONTACT PERSON_____________________ 
   
         ADDRESS________________________________PHONE ________________________________________ 
 
  B.     My occupation is performed outside the City limits in (Municipality)___________________________________