CLGS-32-8 (8-12)

                NOTICE OF INTENT TO FILE COMBINED RETURNS
                AND MAKE COMBINED PAYMENTS

Date:
TO: (List County-wide Collector with whom you will no longer be filing)

FROM: (Employer Name)                                                                                                                 FEIN:

CORPORATE ADDRESS:

CITY:                                                                                                                          STATE: ZIP CODE:

PSD of business location where employer’s headquarters are located (if in state) or business location where employer is filing monthly 
                      (if headquarters are outside of Pennsylvania).
PSD NAME:                       PSD CODE:                                    

Please be advised that _________________________________________________, is hereby filing this Notice of Intent to File Combined Returns
and Payments of the Local Earned Income Tax withheld from all employees who are employed in the Commonwealth of Pennsylvania with 
(list name and address of County-wide collector with whom you will now be filing): _________________________________________________
__________________________________________________________________________________________________________________,
Tax Officer for the _______________________ County Tax Collection District, effective ____________________________.

Attach separately a list of all business addresses in PA.

SIGNATURE OF RESPONSIBLE PERSON:

NAME OF RESPONSIBLE PERSON/CONTACT:                            

CONTACT PHONE NUMBER:                                                                                            CONTACT EMAIL:

ADDRESS:

CITY:                                                                                                                          STATE: ZIP CODE