CLGS-32-4 (8-12)

                                           EMPLOYER REGISTRATION
                                       Local Earned Income Tax Withholding
        You are entitled to receive a written explanation of your rights with regard to the audit, appeal, enforcement, refund and collection of local taxes. Contact your Tax Officer.             

EMPLOYER INFORMATION
EMPLOYER BUSINESS NAME (Use Federal ID Name)

MAIN CORPORATE/BUSINESS LOCATIONNo- STREET ADDRESS (PO Box, RD or RR)

SECOND LINE OF ADDRESS

CITY                                                                                                             STATE                                ZIP

EMPLOYER BUSINESS LOCATION    - STREET ADDRESS WITHIN PA (PO Box,if same asRDabove,or RR)leave blank. No

SECOND LINE OF ADDRESS

CITY OR POST OFFICE                                                                                              STATE                                ZIP

MUNICIPAL TAXING AUTHORITY (City, Borough or Township) IN WHICH FACILITY OR BUSINESS IS LOCATED 

COUNTY                                                                                         BUSINESS PHONE NUMBER                                            BUSINESS FAX NUMBER

EMPLOYER PA BUSINESS LOCATION PSD CODE                                                                   FEDERAL EIN OR SOCIAL SECURITY #

ORGANIZATION
TYPE OF ORGANIZATION 
         LLC                 Individual Proprietorship                 Partnership                 Association                Fiduciary                 Corporation
PRIMARY NATURE/OPERATION OF BUSINESS                                  

DATE OF INCORPORATION (MM/DD/YYYY)                                                                                        DATE OPERATION BEGAN AT THIS LOCATION (MM/DD/YYYY)

ACCOUNTING INFORMATION

Does your organization have multiple site locations within Pennsylvania? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes       No

Has your organization opted to remit EIT for employees at all locations to a single Tax Collection District?  . . . . . . . . . . .      Yes       No

If YES, please insert 2-digit code for Tax Collection District Selected (choose. . . . . . .from. . . .list. .on.reverse side)

                      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.
PRIMARY CONTACT INDIVIDUAL (First Name, Last Name)

TITLE                               

PRIMARY CONTACT PHONE NUMBER                                                                                                                             PRIMARY CONTACT EMAIL ADDRESS

SIGNATURE OF PRIMARY CONTACT INDIVIDUAL                                                                                  (MM/DD/YYYY)                                                               DATE  

CLGS-32-4 (8-12)                                              Tax Collection Districts

TCD CodeTax Collection DistrictTCD CodeTax Collection District
01 ADAMS TAX COLLECTION DISTRICT          32         INDIANA TAX COLLECTION DISTRICT
70 ALLEGHENY CENTRAL TAX COLLECTION DISTRICT33       JEFFERSON TAX COLLECTION DISTRICT
71 ALLEGHENY NORTH TAX COLLECTION DISTRICT34         JUNIATA TAX COLLECTION DISTRICT
72 ALLEGHENY SOUTHEAST TAX COLLECTION DISTRICT35     LACKAWANNA TAX COLLECTION DISTRICT
73 ALLEGHENY SOUTHWEST TAX COLLECTION DISTRICT36     LANCASTER TAX COLLECTION DISTRICT
03 ARMSTRONG TAX COLLECTION DISTRICT      37         LAWRENCE TAX COLLECTION DISTRICT
04 BEAVER TAX COLLECTION DISTRICT         38         LEBANON TAX COLLECTION DISTRICT
05 BEDFORD TAX COLLECTION DISTRICT        39         LEHIGH TAX COLLECTION DISTRICT
06 BERKS TAX COLLECTION DISTRICT          40         LUZERNE TAX COLLECTION DISTRICT
07 BLAIR TAX COLLECTION DISTRICT          41         LYCOMING TAX COLLECTION DISTRICT
08 BRADFORD TAX COLLECTION DISTRICT       42         MCKEAN TAX COLLECTION DISTRICT
09 BUCKS TAX COLLECTION DISTRICT          43         MERCER TAX COLLECTION DISTRICT
10 BUTLER TAX COLLECTION DISTRICT         44         MIFFLIN TAX COLLECTION DISTRICT
11 CAMBRIA TAX COLLECTION DISTRICT        45         MONROE TAX COLLECTION DISTRICT
12 CAMERON TAX COLLECTION DISTRICT        46         MONTGOMERY TAX COLLECTION DISTRICT
13 CARBON TAX COLLECTION DISTRICT         47         MONTOUR TAX COLLECTION DISTRICT
14 CENTRE TAX COLLECTION DISTRICT         48         NORTHAMPTON TAX COLLECTION DISTRICT
15 CHESTER TAX COLLECTION DISTRICT        49         NORTHUMBERLAND TAX COLLECTION DISTRICT
16 CLARION TAX COLLECTION DISTRICTY TAX COLLECTION50 DISTRICTPERR
17 CLEARFIELD TAX COLLECTION DISTRICT     51         PHILADELPHIA TAX COLLECTION DISTRICT
18 CLINTON TAX COLLECTIO DISTRICT         52         PIKE TAX COLLECTION DISTRICT
19 COLUMBIA TAX COLLECTION DISTRICT       53         POTTER TAX COLLECTION DISTRICT
20 CRAWFORD TAX COLLECTION DISTRICT       54         SCHUYLKILL TAX COLLECTION DISTRICT
21 CUMBERLAND TAX COLLECTION DISTRICT     55         SNYDER TAX COLLECTION DISTRICT
22 DAUPHIN TAX COLLECTION DISTRICT        56         SOMERSET TAX COLLECTION DISTRICT
23 DELAWARE TAX COLLECTION DISTRICT       57         SULLIVAN TAX COLLECTION DISTRICT
24 ELK TAX COLLECTION DISTRICTSUSQUEHANNA TAX58COLLECTION DISTRICT
25 ERIE TAX COLLECTION DISTRICT           59         TIOGA TAX COLLECTION DISTRICT
26 FAYETTE TAX COLLECTION DISTRICT        60         UNION TAX COLLECTION DISTRICT
27 FOREST TAX COLLECTION DISTRICT         61         VENANGO TAX COLLECTION DISTRICT
28 FRANKLIN TAX COLLECTION DISTRICT       62         WARREN TAX COLLECTION DISTRICT
29 FULTON TAX COLLECTION DISTRICT         63         WASHINGTON TAX COLLECTION DISTRICT
30 GREENE TAX COLLECTION DISTRICT         64         WAYNE TAX COLLECTION DISTRICT
31 HUNTINGDON TAX COLLECTION DISTRICT     65         WESTMORELAND TAX COLLECTION DISTRICT
                                          66         WYOMING TAX COLLECTION DISTRICT
                                          67         YORK TAX COLLECTION DISTRICT