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RESIDENCY CERTIFICATION FORM Local Earned Income Tax Withholding TO E M P L O Y E R S / TA X PAY E R S : This form is to be used by employers and/or taxpayers to report essential information for the collection and distribution of Local Earned Income Taxes to the local EIT collector. This form must be utilized by employers when a new employee is hired or when a current employee notifies employer of a name and/or address change. Use the Address Search Application at www.newPA.com/Act32 to determine PSD codes, EIT rates and tax collector contact information.
EMPLOYEE INFORMATION – RESIDENCE LOCATION NAME (Last Name, First Name, Middle Initial)
SOCIAL SECURITY NUMBER
STREET ADDRESS (No PO Box, RD or RR)
ADDRESS LINE 2
CITY
STATE
ZIP CODE
DAYTIME PHONE NUMBER
MUNICIPALITY (City, Borough or Township)
COUNTY
RESIDENT PSD CODE
TOTAL RESIDENT EIT RATE
EMPLOYER INFORMATION – EMPLOYMENT LOCATION EMPLOYER BUSINESS NAME (Use Federal ID Name)
EMPLOYER FEIN
STREET ADDRESS WHERE ABOVE EMPLOYEE REPORTS TO WORK (No PO Box, RD or RR)
ADDRESS LINE 2
CITY
STATE
ZIP CODE
PHONE NUMBER
MUNICIPALITY (City, Borough or Township)
COUNTY
WORK LOCATION PSD CODE
WORK LOCATION NON-RESIDENT EIT RATE
CERTIFICATION Under penalties of perjury, I (we) declare that I (we) have examined this information, including all accompanying schedules and statements and to the best of my (our) belief, they are true, correct and complete. SIGNATURE OF EMPLOYEE
PHONE NUMBER
DATE (MM/DD/YYYY)
EMAIL ADDRESS
For information on obtaining the appropriate MUNICIPALITY (City, Borough, Township), PSD CODES and EIT (Earned Income Tax) RATES, please refer to the Pennsylvania Department of Community & Economic Development website:
