06. RESIDENCY CERTIFICATION FORM

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)

First NameMiddle NameLast Name
SOCIAL SECURITY NUMBER
SSN #Format: 0 0 0 0 0 0 0 0 0.
STREET ADDRESS (NoPO Box, RD or RR)

SECOND LINE OF ADDRESS

CITYSTATE

ZIP CODE
DAYTIME PHONE NUMBER
Format: (000) 000-0000.
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)
SECOND LINE OF ADDRESS
CITY
STATE
ZIP CODE
PHONE NUMBER
MUNICIPALITY (City, Borough or Township)
COUNTY
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*
DATE (MM/DD/YYYY)

MonthDayYear
Date
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:

RESIDENCY CERTIFICATION FORM

TO EMPLOYERS/TAXPAYERS:

EMPLOYEE INFORMATION - RESIDENCE LOCATION

EMPLOYER INFORMATION - EMPLOYMENT LOCATION

CERTIFICATION