Ebensburg

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Local Services Tax – Exemption Certificate

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Document Overview

This is a two-page Local Services Tax (LST) Exemption Certificate application form from Ebensburg, Pennsylvania. It allows residents to apply for an exemption from the Local Services Tax based on specific criteria such as multiple employers, low income, or military status.

Application Instructions

  • The completed application and supporting documents must be submitted to both the employer and the political subdivision (municipality or school district) where the applicant is principally employed.
  • The form must be signed and dated.
  • No exemption will be approved until proper documentation is received.

Applicant Information Required

Applicants must provide:

  • Name
  • Address (City/State, Zip)
  • Social Security Number
  • Phone Number

Reasons for Exemption (Select One)

  1. Multiple Employers: Attach a current pay statement from the principal employer showing tax withheld. List all employers on the reverse side. Notify other employers within two weeks if your principal place of employment changes.
  2. Low Income: If expected total earned income and net profits from all sources within the municipality/school district will be less than $[blank] (municipality or school district), attach copies of last pay statements or W-2 for the prior year. Self-employed individuals must also attach PA Schedule C, F, or RK-1 for the prior year.
  3. Active Duty Military: Attach copy of orders directing you to active duty status. Annual training is not eligible. You must notify the tax office when discharged from active duty.
  4. Military Disability: Attach copy of discharge orders and a statement from the United States Veterans Administrator documenting 100% permanent disability.

Employer Instructions

  • Once the certificate is received, employers shall not withhold LST for the portion of the calendar year covered by the certificate, unless otherwise instructed by the tax collector.
  • Employers must provide: Tax Office name, Address (City/State, Zip), and Phone Number.

Important Note to Employers

  1. Municipalities are required by law to exempt employees whose earned income from all sources (including self-employment) in their municipality is less than $12,000 when the levied rate exceeds $10. 00.
  2. School districts may or may not levy an LST. If they do, the income exemption may differ from the municipality and can range from $0 to $11,999.
  3. Employers should contact the tax office where their business worksites are located to obtain specific information.

Reverse Side: Employment Information

The reverse side of the form is used to list all places of employment for the applicable tax year.

  • Primary Employer: Must be listed under #1.
  • Secondary Employers: Listed under columns 2–6.
  • Self-Employed: Write “SELF” under Employer Name column.

Each employer entry requires:

  • Employer Name, Address (including Address 2 if applicable), City/State/Zip, Municipality, Phone
  • Start Date, End Date
  • Status (Full-Time or Part-Time)
  • Gross Earnings

Declaration and Signature

At the bottom of the reverse side, the applicant must declare under penalty of law that the information provided is true and correct.

  • Signature line
  • Date line

All information received by the Tax Collector is considered confidential and used only for official purposes related to collection, administration, and enforcement of the Local Services Tax.

Form Identifier: LST Exemption 10-07

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