RESIDENCY CERTIFICATION FORM

CLGS-32-6 (8-11)
RESIDENCY CERTIFICATION FORM
Local Earned Income Tax Withholding
TO EMPLOYERS/TAXPAYERS:
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. 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.
EMPLOYEE INFORMATION - RESIDENCE LOCATION
NAME (Last Name, First Name, Middle Initial)
SOCIAL SECURITY NUMBER
SOCIAL SECURITY NUMBER
SOCIAL SECURITY NUMBER
SOCIAL SECURITY NUMBER
SOCIAL SECURITY NUMBER
SOCIAL SECURITY NUMBER
SOCIAL SECURITY NUMBER
SOCIAL SECURITY NUMBER
SOCIAL SECURITY NUMBER
STREET ADDRESS (NoPO Box, RD or RR)
SECOND LINE OF ADDRESS
CITY STATE
CITY STATE
ZIP CODE
DAYTIME PHONE NUMBER
MUNICIPALITY (City, Borough or Township)
COUNTY RESIDENT PSD CODE
COUNTY RESIDENT PSD CODE
COUNTY RESIDENT PSD CODE
COUNTY RESIDENT PSD CODE
COUNTY RESIDENT PSD CODE
COUNTY RESIDENT PSD CODE
COUNTY RESIDENT PSD CODE
TOTAL RESIDENT EIT RATE
EMPLOYER INFORMATION - EMPLOYMENT LOCATION
EMPLOYER BUSINESS NAME (Use Federal ID Name)
EMPLOYER FEIN
EMPLOYER FEIN
EMPLOYER FEIN
EMPLOYER FEIN
EMPLOYER FEIN
EMPLOYER FEIN
EMPLOYER FEIN
EMPLOYER FEIN
EMPLOYER FEIN
STREET ADDRESS WHERE ABOVE EMPLOYEE REPORTS TO WORK (NoPO Box, RD or RR)
SECOND LINE OF ADDRESS
CITY STATE
CITY STATE
ZIP CODE PHONE NUMBER
ZIP CODE PHONE NUMBER
MUNICIPALITY (City, Borough or Township)
COUNTY WORK LOCATION PSD CODE
COUNTY WORK LOCATION PSD CODE
COUNTY WORK LOCATION PSD CODE
COUNTY WORK LOCATION PSD CODE
COUNTY WORK LOCATION PSD CODE
COUNTY WORK LOCATION PSD CODE
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.
DATE (MM/DD/YYYY)

MonthDayYear
Date
PHONE NUMBER EMAIL ADDRESS
example@example.com
PHONE NUMBER EMAIL ADDRESS
example@example.com
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:
Should be Empty:

CLGS-32-6 (8-11)

RESIDENCY CERTIFICATION FORM

Local Earned Income Tax Withholding

TO EMPLOYERS/TAXPAYERS:

EMPLOYEE INFORMATION - RESIDENCE LOCATION

EMPLOYER INFORMATION - EMPLOYMENT LOCATION

CERTIFICATION