CLGS-32-5 (06-13)

                                                                 EMPLOYER QUARTERLY RETURN
                                           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 BUSINESS NAME (Use Federal ID Name)

EMPLOYER BUSINESS LOCATION - STREET ADDRESS (PONoBox, RD or RR)

SECOND LINE OF ADDRESS

CITY                                                                                                       STATE                                ZIP

MUNICIPAL TAXING AUTHORITY (City, Borough, Township) IN WHICH FACILITY OR BUSINESS IS LOCATED(Attach listing of multiple locations within PA if applicable)

COUNTY                                                                                         BUSINESS PHONE NUMBER                                            BUSINESS FAX NUMBER   

EMPLOYER PSD CODE                    FEDERAL EIN OR SOCIAL SECURITY #                              ACCOUNT NUMBER                                                  YEAR AND QUARTER

1. Total Earned Income Tax Withheld  . . . . . . . . . . . .$              8. Date Period Ended (MM/DD/YYYY). . . . . . . . . . . .
2. Credit or Adjustment  . . . . . . . . .$(attach explanation)            9. Total Pages of This Return  . . . . . . . . . . . . . . . . . .
3. Total of Earned Income Tax Due(line$1 minus line 2) .                   10. Total Number of Employees Listed  . . . . . . . . . . .

4. Total Payments Made this Quarter  . . . . . . . . . . . . .$            If therehas been a change of ownership or other transfer of business during
5. Adjusted Total of EIT Due  . . . . . .$(line 3 minus line 4)            the quarter, attach explanation and give name of present owner and date the
                                                                           change took place.         CHANGE              NO CHANGE
6. Penalty & Interest   ___%per month after                             $
                        (                      due date x line 5)
7.Balance Due with Return   (Add lines 5 and 6)                   . . . .$ Do you expect to pay taxable wages next quarter?        Yes        No

                              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  

                                                                                                           (13) GROSS (14) AMOUNT OF EIT (15) RESIDENT 
   (11) EMPLOYEE’S SOCIAL (12) EMPLOYEE’S NAME/ADDRESSCOMPENSATION PAIDWITHHELD THIS
   SECURITY NUMBER                                                                                         THIS QUARTERQUARTER                             PSD CODE

                                                                           $                               $

                                                                           $                               $

                                                                           $                               $

                                                                           $                               $

(16) FIRST PAGE TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ $

   Make Checks payable to: __________________________
   There will be a $_______ fee for returned payments & checks.            TOTAL Amount Enclosed            . . . . . . .$
                            NOT to be filed with the PA Department of Revenue. Please file with your local EIT Collector.

CLGS-32-5 (06-13) EMPLOYER QUARTERLY RETURN for Local Earned Income Tax Withholding

Employer Business Location: ___________________________________________________________________________  Year and Quarter: ______________

                                                                                                            (13) GROSS (14) AMOUNT OF EIT (15) RESIDENT 
(11) EMPLOYEE’S SOCIAL (12) EMPLOYEE’S NAME/ADDRESSCOMPENSATION PAIDWITHHELD THIS
SECURITY NUMBER                                                                                             THIS QUARTERQUARTER PSD CODE

                       $                                                                                    $

                       $                                                                                    $

                       $                                                                                    $

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(16) THIS PAGE TOTAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ $