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 Eamed 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)
First Name
Last Name
SOCIAL SECURITY NUMBER
STREET ADDRESS (No PO Box, RD or RR)
ADDRESS LINE 2
CITY
STATE
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) Cyanjel Homce Care
EMPLOYER FEIN 8 7 1 3 4 237 2
ADDRESS LINE 2
CITY Pittsburgh
STATE PA
ZIP CODE 15236
PHONE NUMBER 7249129211
Format: (000) 000-0000.
MUNICIPALITY (City, Borough or Township) Pleasant Hills
COUNTY Allegheny
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)
-
Month
-
Day
Year
Date
PHONE NUMBER
Format: (000) 000-0000.
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: dced.pa.gov/Act32
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