Enlarge image | Mail to: Keystone Collections Group PO Box 559 • Irwin PA 15642 LocaL ServiceS Tax Form LST22r2.1 efund appLicaTion r File completed application with Tax Officer do noT FiLe ThiS Form wiTh your earned income Tax reTurn Click here to download LST Exemption Application Name Tax Year Address SSN City/State Phone Zip Reason for Refund (check all that apply) Overpaid by more than $1 Exempt but withheld in error 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 for uSe by ndividuaL i TaxpayerS onLy • empLoyerS do noT SubmiT ThiS form: Contact the Tax Officer at www.KeystoneCollects.com for additional information regarding the Local Services Tax. |
Enlarge image | Mail to: Keystone Collections Group PO Box 559 • Irwin PA 15642 LocaL ServiceS Tax Form LST22r2.1 refund appLicaTion – page 2 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 Tax Officer do noT FiLe ThiS Form wiTh your earned income Tax reTurn Click here to download LST Exemption 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. |