LOCAL SERVICES TAX - EXEMPTION CERTIFICATE - Application for Exemption From Local Services Tax

Sep 19, 2026

Application for exemption from Local Services Tax (LST) requires completion of the form and submission to both the employer and the political subdivision that levies LST where the applicant is principally employed. The certificate must be signed and dated, and no exemption is approved until proper documentation is received. The form collects taxpayer identity, reason for exemption (multiple employers, income below threshold, active duty military, or military disability), and employer employment details for the applicable tax year, including certification under penalty of law and confidentiality notice.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Tax Year and Application Requirements

Reason for Exemption

Employer Employment Information

Important Notes and Declarations

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. 2023 Dunmore Borough 12,000.00 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

FAQs

Where must the Local Services Tax exemption application and supporting documents be submitted?

Submit the completed application and all necessary supporting documents to your employer and to the political subdivision levying the Local Services Tax where you are principally employed.

When will an LST exemption be approved?

No exemption is approved until proper documentation has been received.

What documentation is required for an exemption due to active duty military status?

Attach a copy of orders directing you to active duty status. Annual training is not eligible, and you must advise the tax office when discharged.

Sep 19, 2026

Upload by Bill Black