LOCAL SERVICES TAX – EXEMPTION CERTIFICATE 
                     ___________________________________________ 
                                              Tax Year 
                                               
               APPLICATION FOR EXEMPTION FROM LOCAL SERVICES TAX 
 
¾ 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 
  where you are principally employed. 
¾ This application for exemption from the Local Services Tax must be signed and dated. 
¾ No exemption will be approved until proper documentation has been received. 
 
Name: _____________________________________   Soc Sec #: ____________________________________ 
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 _____________________________________________ (municipality or school 
               district) WILL BE LESS THAN $___________: Attach copies of your last pay statements or 
               your W-2 for the year prior. 
                
               If you are self-employed, please attach a copy of your PA Schedule C, F, or RK-1 for the prior 
               year. 
 
3.  __________ ACTIVE DUTY MILITARY EXEMPTION: Please attach a copy of your orders directing you to 
               active duty status. Annual training is not eligible for exemption. You are required to advise the 
               tax office when you are discharged from active duty status. 
 
4.  __________ MILITARY DISABILITY EXEMPTION: Please attach 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 
tax collector to withhold the tax. 
 
Tax Office: _________________________________  
Address: ___________________________________ Phone #: _____________________________________ 
City/State: _________________________________ Zip: _________________________________________ 
 
                                   IMPORTANT NOTE TO EMPLOYERS 
  1. 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 when the levied rate exceeds $10.00. 
  2. The school district for the municipality in which your worksite(s) is located may or may not levy an LST. If it does, the 
     income exemption provided may differ from the municipality and can be anywhere from $0 to $11,999.  
  3. Contact the tax office where your business worksites are located to obtain this information.  

LST Exemption 10-07 

Employment Information: List all places of employment for the applicable tax year. Please list your 
PRIMARY EMPLOYER under #1 below and your secondary employers under the other columns. If self 
employed, write SELF under Employer Name column. 
 
                   1.  PRIMARY EMPLOYER   2.          3. 
Employer Name                                        
Address                                              
Address 2                                            
City, State Zip                                      
Municipality                                         
Phone                                                
Start Date                                           
End Date                                             
Status (FT or PT)                                    
Gross Earnings                                       
 
                    4.             5.                6. 
Employer Name                                        
Address                                              
Address 2                                            
City, State Zip                                      
Municipality                                         
Phone                                                
Start Date                                           
End Date                                             
Status (FT or PT)                                    
Gross Earnings                                       
 
PLEASE NOTE: 
 
All information received by the Tax Collector is considered to be CONFIDENTIAL and is only used for 
official purposes relating to the collection, administration and enforcement of the LOCAL SERVICES 
TAX. 
 
I DECLARE UNDER PENALTY OF LAW THAT THE INFORMATION STATED ON AND 
ATTACHED TO THIS FORM IS TRUE AND CORRECT: 
 
SIGNATURE: _________________________________________________ DATE: ____________________ 

LST Exemption 10-07