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CLGS-32-6 6-13 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 BUSINESS NAME Use Federal ID Name EMPLOYER FEIN PHONE NUMBER 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 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 www. 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 BUSINESS NAME Use Federal ID Name EMPLOYER FEIN PHONE NUMBER 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. 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 BUSINESS NAME Use Federal ID Name EMPLOYER FEIN PHONE NUMBER 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 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 www.

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