RESIDENCY CERTIFICATION FORM
Local Earned Income Tax Withholding

TO EMPLOYERS/TAXPAYERS:

This form is to be used by employers and taxpayers to report essential information for the collection and distribution of Local Earned Income Taxes to the local EIT collector. This form must be used by employers when a new employee is hired or when a current employee notifies employer of a name or address change. Use the Address Search Application at dced.pa.gov/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

DATE (MM/DD/YYYY)

PHONE NUMBER

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: dced.pa.gov/Act32

RESIDENCY CERTIFICATION FORM Local Earned Income Tax Withholding

TO EMPLOYERS/TAXPAYERS:

EMPLOYEE INFORMATION – RESIDENCE LOCATION

EMPLOYER INFORMATION – EMPLOYMENT LOCATION

CERTIFICATION

RESIDENCY CERTIFICATION FORM
Local Earned Income Tax Withholding