Local Services Tax – Exemption Certificate

Overview

This document is an application form for exemption from the Local Services Tax (LST) in Ebensburg, PA. It is designed for individuals who need to prove they qualify for an exemption based on specific criteria, such as having multiple employers or low income.

How to Apply

To apply for an exemption, you must complete this form and present it to two parties:

• Your employer.
• The political subdivision (municipality or school district) where you are principally employed.

The form must be signed and dated. No exemption will be approved until proper documentation is received.

Exemption Reasons

You must select one of the following reasons for exemption and provide the required supporting documents:

1. Multiple Employers: You must attach a current pay statement from your principal employer showing the tax withheld. You are also required to list all other employers on the reverse side of this form and notify them of any changes in your principal place of employment within two weeks.
2. Low Income: If your expected total earned income and net profits from all sources within the municipality or school district will be less than a specific dollar amount, you may qualify. You must attach copies of your last pay statements or W-2 from the prior year. If self-employed, attach PA Schedule C, F, or RK-1.
3. Active Duty Military: You must attach a copy of your orders directing you to active duty status. Note that annual training is not eligible for exemption. You must advise the tax office when discharged from active duty.
4. Military Disability: You must attach a copy of your discharge orders and a statement from the United States Veterans Administrator documenting a 100% permanent disability.

Employer Instructions

Once an employer receives this certificate, they shall not withhold the Local Services Tax for the portion of the calendar year covered by the certificate, unless instructed otherwise by the tax collector.

Important Note to Employers

• Income Threshold: Municipalities are required by law to exempt employees whose earned income from all sources is less than $12,000 when the levied rate exceeds $10. 00.
• School Districts: School districts may or may not levy an LST. If they do, the income exemption limit can vary from $0 to $11,999.
• Verification: Employers should contact the tax office where their business is located to obtain specific information regarding local rates and limits.

Reverse Side Requirements

The second page of the form is dedicated to listing employment information. You must list your Primary Employer under column #1 and any secondary employers in the other columns. If self-employed, write "SELF" under Employer Name.

For each employer, you must provide:

• Employer Name and Address
• Municipality
• Phone Number
• Start Date and End Date
• Status (Full-Time or Part-Time)
• Gross Earnings

The form concludes with a declaration under penalty of law that the information provided is true and correct, requiring a signature and date.