CLGS-32-1 (10-2 )3
                                                                    TAXPAYER ANNUAL
                                           LOCAL EARNED INCOME TAX RETURN                                                                                                                  KeystoneCollects.com
       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.
e-file at efile.KeystoneCollects.com                                                                                                                                        Tax Year
DATES LIVING AT EACH ADDRESS               STREET ADDRESS (No PO Box, RD or RR)                                                               CITY OR POST OFFICE                    STATE     ZIP
       /  /       TO /        /
       /  /       TO /        /
If you moved during the tax year, file one return for each municipality (enter PSD Code for each jurisdiction). Use Part-Year Resident Schedule on back to calculate income and taxes for each return.
LAST NAME, FIRST NAME, MIDDLE INITIAL                                                                                              SPOUSE’S LAST NAME, FIRST NAME, MIDDLE INITIAL

STREET ADDRESS (No PO box, RD or RR)                                                                                                                         COUNTY

SECOND LINE OF ADDRESS                                                                                                                                       SCHOOL DISTRICT

CITY OR POST OFFICE                                                 STATE                                                          ZIP CODE                  MUNICIPALITY

DAYTIME PHONE NUMBER                                       RESIDENT PSD CODE                                                       EXTENSION REQUEST FORM
                                                                                                                                            see Instructions A5                  AMENDED RETURN
                                                                                                                                   Download form at KeystoneCollects.com
                                                                                                                                                                            Spouse’s Social Security #
          The calculations reported in the first column MUST pertain to the name                                                            Social Security #
                 printed in the column, regardless of which spouse appears first.
                       Combining income is NOT permitted.
                                                                                                                                   If you had NO EARNED INCOME            If you had NO EARNED INCOME
                  USE ONLY BLACK OR BLUE INK TO COMPLETE THIS FORM                                                                 check the reason why:                    check the reason why:
          Include supporting documentation to verify income and credits below.                                                     disabled                  student        disabled        student
                                                                                                                                   deceased                  military       deceased        military
                                                                                                                                   homemaker                 retired        homemaker       retired
       Single     Married, Filing Jointly Married, Filing Separately
                                                                                                                                   unemployed                               unemployed
1. Gross compensation as reported on W-2(s) (enclose W-2s) ......................................
                                                                                                                                                                      .00                              .00
2. Unreimbursed Employee Business Expenses (enclose PA Schedule UE) .............                                                           , ,                             ,              ,
                                                                                                                                                                      .00                              .00
3. Other Taxable Income (see Instructions; enclose supporting documents) ....................                                               , ,                             ,              ,
                                                                                                                                                                      .00                              .00
4. Total Taxable Income (subtract Line 2 from Line 1 and add Line 3)................................                                        , ,                             ,              ,
                                                                                                                                                                      .00                              .00
5. Net Profits (enclose PA Schedules) ............................................................................................          , ,                             ,              ,
NON-TAXABLE S-CORP earnings check this box                (enclose S-Corp Schedule)                                                                                   .00                              .00
6. Net Loss (enclose PA Schedules) ...............................................................................................          , ,                             ,              ,
                                                                                                                                                                      .00                              .00
7. Total Taxable Net Profit (subtract Line 6 from Line 5; if less than zero, enter zero) ...                                                , ,                             ,              ,
                                                                                                                                                                      .00                              .00
8. Total Taxable Income and Net Profit (add Line 4 and Line 7) .......................................                                      , ,                             ,              ,
                                                                                                                                                                      .00                              .00
9. Tax Liability (Line 8 multiplied by                     ) ..............................................                                 , ,                             ,              ,
                                                                                                                                                                      .00                              .00
10. Income Tax Withheld (may not equal W-2; see Instructions) ............................................                                  , ,                             ,              ,
                                                                                                                                                                      .00                              .00
11. Quarterly and Extension Payments/Credit From Previous Year ............................                                                 , ,                             ,              ,
                                                                                                                                                                      .00                              .00
                                                                                                                                            , ,                             ,              ,
12. Credits:       Out-of-State        Philadelphia and       Act 172                                                                                                 .00                              .00
13. PAYMENTS and CREDITS (add Lines 10, 11, and 12) ....................................................                                    , ,                             ,              ,
                                                                                                                                                                      .00                              .00
14. Refund: enter if $2 or more; or select credit option in Line 15 ..........................                                              , ,                             ,              ,
                                                                                                                                                                      .00                              .00
                                                                                                                                            , ,                             ,              ,
15. Credit to Taxpayer/Spouse if $2 or more, apply credit as follows ..............................
          Credit to next year             Credit to spouse                                                                                                            .00                              .00
                                                                                                                                            , ,                             ,              ,
16. TAX BALANCE DUE (Line 9 minus Line 13 ) .......................................................................                                                   .00                              .00
17. Penalty after Due Date (multiply Line 16 by ____ x number of months late) ...................                                           , ,                                  ,         ,
                                                                                                                                                                      .00                              .00
18. Interest after Due Date (multiply Line 16 by 0.00583 x number of months late) ................                                          , ,                             ,              ,
                                                                                                                                                                      .00                              .00
19. TOTAL PAYMENT DUE (add Lines 16, 17 and 18) .........................................................                                   , ,                                  ,         ,
                                                                                                                                                                      .00                              .00
Do not photocopy or print more than one W-2 or Form 1099 on the same page.                                                                  , ,                                  ,         ,
                                           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.
YOUR SIGNATURE                                                                   SPOUSE’S SIGNATURE (if filing jointly)                                                               DATE (MM/DD/YYYY)

PREPARER’S PRINTED NAME AND SIGNATURE                                                                                                                                     PHONE NUMBER

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S-CORPORATION REPORT                                                                                 TAXPAYER                       TAXPAYER SPOUSE
Report passive or unearned S-Corporation income (losses) 
that were reported on your PA-40 Return.                                                    $                                  .0 0 $                   .0 0

PART-YEAR RESIDENT SCHEDULE
If you moved to another municipality, use this schedule to calculate income and taxes owed to each taxing jurisdiction. File                         one local earned 
income tax return for each PA municipality. Report taxable income, tax paid and tax liability for each PA municipality separately on each return. 
Current Residence                                                                           (street address)                        # months at this address
   (required)                                                                                                                       Use full # months; not fraction of month
                                                                                            (municipality, State, ZIP)
Employer (1)
Income        $            divided by 12 months X        (months at this address) = $ 
Withholding   $            divided by 12 months X        (monthsUse full # months;at thisnotaddress)fraction of month= $            PSD Code - Current Residence
Employer (2)
Income        $            divided by 12 months X        (months at this address) = $ 
Withholding   $            divided by 12 months X        (months at this address) = $
                                                                Use full # months; not fraction of month
Current Residence Total Income $                       Total Local Tax Withheld $ 
Put the Total Income on Line 1 and the Tax Withheld on Line 10 of the Local Earned Income Tax Return for your current residence taxing jurisdiction.
Previous Residence                                                                          (street address)                        # months at this address
   (required)                                                                                                                       Use full # months; not fraction of month
                                                                                            (municipality, State, ZIP)
Employer (1)
Income        $            divided by 12 months X        (months at this address) = $ 
                                                                                                                                    PSD Code - Previous Residence
Withholding   $            divided by 12 months X        (months at this address) = $ 
                                                                Use full # months; not fraction of month
Employer (2)
Income        $            divided by 12 months X        (months at this address) = $                                                          FAQ
Withholding   $            divided by 12 months X        (months at this address) = $
                                                                Use full # months; not fraction of month
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Previous Residence Total Income $                      Total Local Tax Withheld $                                                   for answers to frequently asked questions
Put the Total Income on Line 1 and the Tax Withheld on Line 10 of the Local Earned Income Tax Return for your previous residence taxing jurisdiction.

LINE 10: LOCAL EARNED INCOME TAX WITHHELD WORKSHEET
Complete worksheet if you work in an area where the non-resident tax rate exceeds your home resident rate
                (1)               (2)              (3)                                      (4)                          (5)        (6)                 (7)
                                                                     Workplace Location                      Column (4) minus       Disallowed       Credit Allowed for 
            Local Wages    Tax Withheld       Resident EIT Rate      “Non-Resident”                                    Column (3) Withholding Credit Tax Withheld
              W-2 Box 16   W-2 Box 19         Tax Form Line 9                               EIT Rate    If less than 0 enter 0    Col (1) times Col (5) Col (2) minus Col (6)
Example
1.              $10,000.00            $130.00      1.25%                                    1.30%                        0.05%              $5.00                           $125.00
2.
3.

                                                                                                     TOTAL Enter this amount on Line 10
LINE 12: OUT-OF-STATE TAX CREDIT WORKSHEET (see Instructions)
(Credit for income tax paid to non-reciprocal states must first be applied to PA State tax. Credit for taxes paid may not exceed local resident EIT liability.)
Out-of-state income ......................................................................$
       (Use figure from PA Schedule G-L)
Out-of-state tax paid .....................................................................$
       (Use figure from PA Schedule G-L, Line 4.c)                                                                       save time             -file                        online
PA state income tax liability ..........................................................$
       (Out-of-state income x 3.07%)
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Credit available against PA state tax liability ................................$
       (Choose the lesser of the out-of-state tax paid and the PA state income tax liability) 
                  Balance from PA state tax credit .............................................................. $
                           (subtract PA state tax liability from out-of-state tax paid)
Out-of-state income ......................................................................$
       (Use figure from PA Schedule G-L)
       Local Rate Multiplier (see Line 9 for local tax rate) ................................................. $
                  (Out-of-state income times local resident tax rate)

LOCAL EARNED INCOME TAX CREDIT FOR LINE 12 ........................................................................................ $
       (Enter the lesser of the Balance from PA state tax credit and the Local Rate Multiplier on Line 12 of tax return)
                                              A NOTE FOR RETIRED AND/OR SENIOR CITIZENS
If you are retired and are no longer receiving a salary, wages or income from a business, you may not owe an earned income tax. Social Security payments, 
payments from qualified pension plans, interest and/or dividends accrued from bank accounts and/or investments are not subject to local earned income tax. If you 
received an Annual Local Earned Income Tax Return, please check the “retired” box on the front of the form and return it to your tax collector. If you still receive wages 
from a part-time employer or income from a business, you will need to file a return and pay the local earned income tax.