PA LOCAL 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 *

First

Middle

Last

Social Security Number *

STREET ADDRESS (No PO Box, RD or RR) *

Address Line 1

Address Line 2

City

State

Zip Code

DAYTIME PHONE NUMBER

RESIDENT PSD CODE

Leave blank if you do not know it

TOTAL RESIDENT EIT RATE

Leave blank if you do not know it

EMPLOYER INFORMATION – EMPLOYMENT LOCATION

EMPLOYER BUSINESS NAME (Use Federal ID Name)

EMPLOYER FEIN

ADDRESS WHERE ABOVE EMPLOYEE REPORTS TO WORK (No PO Box, RD or RR)

Address Line 1

Address Line 2

City

State

Zip Code

PHONE NUMBER

WORK LOCATION PSD CODE

Leave blank if you do not know it

WORK LOCATION NON-RESIDENT EIT RATE

Leave blank if you do not know it

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 *

Clear Signature

DATE (MM/DD/YYYY) *

PHONE NUMBER

EMAIL ADDRESS

EMPLOYEE EMPLOYMENT 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.newPA.com

rsi-palocal

PA LOCAL RESIDENCY CERTIFICATION FORM

Local Earned Income Tax Withholding

TO EMPLOYERS/TAXPAYERS:

EMPLOYEE INFORMATION – RESIDENCE LOCATION

EMPLOYER INFORMATION – EMPLOYMENT LOCATION

CERTIFICATION