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Capital Tax Collection Bureau
2301 North Third Street ▪ Harrisburg, PA 17110
(717) 234-3217 (Phone) ▪ (717) 234-2962 (Fax)
LOCAL EARNED INCOME TAX RETURN
CERTIFICATE OF RESIDENCE FORM
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This form is to be used by employers and/or taxpayers to report essential information for the collection and distribution of Local Earned Income Taxes (EIT).
This form must be utilized by employers when a new employee is hired or when a current employee notifies employer of a name and/or address change.
SECTION 1 – EMPLOYEE PHYSICAL RESIDENT ADDRESS
NAME (Last, First, Middle Initial) SOCIAL SECURITY NUMBER
PHYSICAL STREET ADDRESS (Not PO Box or c/o Address – See Section 2 below) BIRTHDATE
CITY STATE ZIP CODE DAYTIME PHONE NUMBER
COUNTY SCHOOL DISTRICT MUNICIPALITY (City, Borough, Township)
DATE YOU BECAME A RESIDENT OF ABOVE ADDRESS PSD CODE (6 digit) TOTAL RESIDENT EIT RATE
SECTION 2 – EMPLOYEE MAILING ADDRESS
MAILING ADDRESS (Complete only if different from physical address in Section 1)
CITY STATE ZIP CODE
SECTION 3 – SPOUSE ALSO RESIDING AT ABOVE ADDRESS
NAME (Last, First, Middle Initial) BIRTHDATE SOCIAL SECURITY NUMBER
SECTION 4 – EMPLOYER LOCAL EMPLOYMENT LOCATION – LOCAL PHYSICAL ADDRESS
EMPLOYER NAME (Use Federal ID Name) EMPLOYER FEIN
LOCAL STREET ADDRESS (Not PO Box)
CITY STATE ZIP CODE PHONE NUMBER
COUNTY SCHOOL DISTRICT
MUNICIPALITY (City, Borough, Township) WORK PSD CODE (6 digit) MUNICIPAL NON-RESIDENT EIT RATE
SECTION 5 – CERTIFICATION
SIGNATURE OF EMPLOYEE DATE
PHONE NUMBER EMAIL ADDRESS
For information on obtaining the appropriate MUNICIPALITY (City, Borough, Township) PSD CODES and Earned Income Tax RATES to enter in
Sections 1 and 4 above, please refer to the Pennsylvania Department of Community and Economic Development website:
www.newPA.com
Select Get Local Gov Support > Municipal Statistics > EIT/PIT/LST Tax Registers
