LST-3 Local Services Tax Individual Return               LST

                                                                                                                         *LSTQ3*
            PO BOX 25156 
            LEHIGH VALLEY, PA 18002-5156
                                                                                Scan for                           Remit this completed form by mail to:       *COPY*
                                                                                   more                            HAB-LST 
                                                                                                                   PO BOX 25156 
                                                                          information                              LEHIGH VALLEY, PA 18002-5156
                                                                                             For more options, visit: www.berk-e.com 
                                                                                    For assistance, contact:wecare@palocaltax.com
       Name 
       Address                                                          The Local Services  Tax is a local tax due from all individuals who are         
                                                                        employed within the taxing jurisdiction printed below. All Federal Employees 
       City                                                             and all Self-Reporting Individuals who perform services of any kind or        
                                                                        engage in any occupation or professions within the stated Borough, Township, 
       State                                                            or School District are required to pay a Local Services Tax. 
                                                                         
       ZIP                                                              Please complete and return the LST-3 form below with your payment due. If 
                                                                        remitting the annual tax amount due in full, please submit all returns with your 
                                                                        payment at the time of filing. If for some reason you already paid the tax in  
                                                                        another political subdivision, or at another place of employment, provide this 
                                                                        office with proof of payment and we will adjust our records accordingly. If your 
                                                                        primary employment jurisdiction has the Local Services Tax, the tax is not to 
       Enter Your Social Security Number:                               be deducted from the secondary place of employment.
                                                                        . Your cancelled check is sufficient proof of payment.   
                                                                        . Make any corrections to Name, Address, and Work Location. 
                                                                        . There will be an additional fee assessed for returned payments or if no payment is  
                                                                           enclosed for tax due at the time of filing.
                                                                                                                   DO NOT SEPARATE HERE

                                                                                                                         Daytime/Mobile Phone Number*
EMAIL: 

       JURIS NO.                          ACCOUNT NO: 
        
                                                                                                         Quarter______ Year_________
       WORK LOCATION:
                                                                                                         Exemption Enclosed-no tax due  (check here) 

                                                                                    1. Tax Due                    ¸  4      ,        ,                   .
                                                                                                                         
                                                               2. Penalty (line 1  x           ) if paid after due date     ,        ,                   .
                                                                                                                         
                                                            3. Interest (line 1 x          ) per month after due date       ,        ,                   .
                                                                                                                         
                                                                  4.  Total Penalty & Interest (line 2 + line 3)  
                                                                                                                            ,        ,                   .
             WEB
                                                                                                                         
3 3                                                               5. Total of Check Enclosed (line 1 + line 4)              ,,,,                         ..
      Payable to:  HAB-LST 
      BERKHEIMER, PO BOX 25156, LEHIGH VALLEY, PA 18002-5156