Fill - Free fillable Certificate Of Residency Combined PDF form

Instructions for Completing the Residency Certification Form

Please submit your completed form to the Payroll Department for processing.

No changes to your address will be made until the completed form is received.

Click on the link below to look up the PSD codes and rates for your home address and the address

of the DASD building where you work.

http://munstats.pa.gov/Public/FindLocalTax.aspx

Section 1: Employee Information – Complete with your home address information

Section 2: Employer Information – Complete with the address of your primary work location

Section 3: Certification – Sign, date and complete this section before sending the form to the

Payroll Department

RESIDENCY CERTIFICATION FORM

Local Earned Income Tax Withholding

EMPLOYEE INFORMATION – RESIDENCE LOCATION

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.

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

CERTIFICATION

SIGNATURE OF EMPLOYEE DATE (MM/DD/YYYY)

PHONE NUMBER EMAIL ADDRESS

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

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

CLGS-32-6 (05/17)

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.

Fill Online, Printable, Fillable, Blank Certificate Of Residency Combined Form