Pennsylvania Local Services Tax

LST Exemption Certificate

Employee Request for Exemption from Local Services Tax Withholding

INSTRUCTIONS:

Complete this form to request exemption from Local Services Tax (LST) withholding. The LST is a $52 annual tax withheld by employers from employees who work within a Pennsylvania municipality that levies this tax.

Note: Employers must keep this certificate on file. A new certificate must be filed each calendar year to maintain exemption.

EMPLOYEE INFORMATION

Employee Name (Last, First, MI)

Social Security Number

Home Address (Street, City, State, ZIP)

Municipality of Residence

Phone Number

REASON FOR EXEMPTION - Check ONE box that applies

A. Low Income Exemption

I certify that my total earned income from all sources (all employers) will be less than $12,000 for the current calendar year.

B. Multiple Employer Exemption

I certify that I am employed by another employer who is withholding the LST for the same work location municipality. (Provide employer info below)

C. Disability Exemption

I certify that I am exempt due to a permanent disability. (Attach proof of disability such as Social Security determination or VA disability letter)

D. Active Military Exemption

I certify that I am currently serving on active duty in the United States Armed Forces.

IF CLAIMING MULTIPLE EMPLOYER EXEMPTION (B) - Complete this section

Primary Employer Name (Withholding LST)

Primary Employer Phone

Primary Employer Address

EMPLOYEE CERTIFICATION

Under penalties of perjury, I certify that the information provided on this form is true, correct, and complete. I understand that I must notify my employer within two weeks if my circumstances change and I no longer qualify for this exemption. I further understand that false statements may result in penalties and/or prosecution.

Employee Signature

Sign above using your mouse or finger

Date (MM/DD/YYYY)

FOR EMPLOYER USE ONLY

Employer Name

Employer EIN

Work Location Address

Work Location Municipality

Date Received by Employer

Important Reminders:

• This exemption certificate must be renewed each calendar year
• Notify your employer within 2 weeks if your exemption status changes
• Keep a copy of this form for your records
• If claiming disability exemption, attach supporting documentation