LST
                                                                                          LST-1                                               *LST1B*

                   PO BOX 25156 
                   LEHIGH VALLEY, PA 18002-5156                                                             Scan this                                                Remit this completed form by mail to: 
                                                                                                         code to file                                                HAB-LST 
                                                                                                                                                                     PO BOX 25156 
                                                                                                             online:                                                 LEHIGH VALLEY, PA 18002-5156
      Name                                                                                                            For more options, visit: www.berk-e.com 
                                                                                                                  For assistance, contact:wecare@palocaltax.com
      Address 
      City                                                                                              ACCOUNT NO.                                FEDERAL                   EIN: 
                                                                                                         
      State                                                                                             Quarter ______  Year ______  
                                                                                                         
      ZIP                                                                                               JURISDICTION: 
                                                                                                                                                                                         1
                                                                                                         
                                                                                                        PSD: 
                                                                                                         
                                                                                                        BUSINESS LOCATION:
                                                                                                    l Your cancelled check is sufficient proof of payment. 
                                                                                                    l  Make any corrections on this form to Name, Address, and Business Location. 
                                                                                                    l There will be an additional fee assessed for returned payments or if no                               
                                                                                                         payment is enclosed for tax due at the time of filing 

                                                                                                                                                                  Daytime/Mobile Phone Number*
EMAIL: 
For 1b through 1e, enter the            
number of employees for each         1.  # Employees                        2. Tax Withheld                                         3. Payment Information
exemption category.

a. Total number of employees ...........                                   intentionally blank  a. Amount Withheld (same as 2f      )..........................              ,    .
                                                                                                 
b. Employees with NO exemption ..........                                                        
                                                                            ,             .     b. Discount (line 3a x                ) ............................         ,    .
                                                                                                 
c. Exempt fromonly municipal portion of tax ........                        ,             .      c. Net Amount Due (3a-3b) ...................................               ,    .
 
d. Exempt from only school portion of tax ...........                                            
                                                                            ,             .     d. Penalty (line 3c  x            ) after due date ..........                ,    .
                                                                                                 
e. Exempt fromboth municipal & school                                       intentionally blank e. Interest (line 3c  x           ) per month after 
portion of tax  ...........................................................
                                                                                                                                                      due date...            ,    .
Note: 1b+1c+1d+1e should total 1a                                                                
                                            2f.  Total Withheld.......      ,             .     f. Total Penalty & Interest (line 3d + line 3e) ........                     ,    .
                                                                                                                                                                      intentionally blank
                                                                                                g. Late Filing Fee  (                          )     ............ 
                                                                                                 
                                                                                                h. Total of Check Enclosed (line 3c+line 3f)...........                      ,    .
                                                                                                    Check this box if you will have no employees next year:  
                   WEB