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CITY OF PITTSBURGH
2021 LOCAL SERVICE TAX – EXEMPTION CERTIFICATE
A copy of this application for exemption from the Local Services Tax (LST), and all necessary supporting
documents, must be completed and presented to your employer and to the political subdivision levying the Local
Services Tax for the municipality or school district in which you are primarily employed.
This application for exemption from the Local Services Tax must be signed, dated, and given to each
employer.
No exemption will be approved until proper documentation has been received.
PRINT NAME: SOCIAL SECURITY #:
ADDRESS: PHONE #:
CITY – STATE – ZIP:
REASON FOR EXEMPTION
1. MULTIPLE EMPLOYERS: Attach a copy of a current pay statement from your principal employer that
shows the name of the employer, the length of the payroll period and the amount of Local Services Tax withheld.
List all employers on the reverse side of this form. You must notify your other employers of a change in principal
place of employment within two weeks of the change.
2. EXPECTED TOTAL EARNED INCOME AND NET PROFITS FROM ALL SOURCES
WITHIN THE CITY OF PITTSBURGH WILL BE LESS THAN $12,000 : Attach copies of your last pay
statements from all employers or copies of your W-2’s from all employers for the prior year. Also submit copies to
your employer(s).
If you are SELF-EMPLOYED, attach a copy of your PA Schedule C, F, or RK-1 for the prior year.
3. ACTIVE DUTY MILITARY EXEMPTION: Attach a copy of your orders directing you to active duty
status. Annual training is not eligible for exemption. You are required to advise your employer and tax office
when you are discharged from active duty status.
4. MILITARY DISABILITY EXEMPTION: Attach a copy of your discharge orders and a statement from
the United States Veterans Administrator documenting your disability. Only 100% permanent disabilities are
recognized for this exemption.
EMPLOYER: Once you receive this Exemption Certificate, you shall not withhold the Local Services Tax for the
portion of the calendar year for which this certificate applies, unless you are otherwise notified or instructed by
the taxpayer or tax collector to withhold the tax. Employer must retain Exemption Certificate.
Tax Office: LST Exemption Certificate, City of Pittsburgh, Department of Finance,
Address: 414 Grant Street
City, State & Zip: Pittsburgh PA 15219-2476
The municipality is required by law to exempt from the LST employees whose earned income from all sources
(employers and self-employment) in their municipality is less than $12,000.
SIGNATURE: DATE:
For additional information go to www.pittsburghpa.gov/finance/finance.html or call 412-255-2504.
Rev- 7/2019
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