Instructions for Completing the Residency Certification Form
Please submit your completed form to the Payroll Department for processing.
No changes to your address will be made until the completed form is received.
Click on the link below to look up the PSD codes and rates for your home address and the address
of the DASD building where you work.
http://munstats.pa.gov/Public/FindLocalTax.aspx
Section 1: Employee InformationComplete with your home address information
Section 2: Employer InformationComplete with the address of your primary work location
Section 3: CertificationSign, date and complete this section before sending the form to the
Payroll Department
RESIDENCY CERTIFICATION FORM
Local Earned Income Tax Withholding
EMPLOYEE INFORMATION – RESIDENCE LOCATION
TO EMPLOYERS/TAXPAYERS:
This form is to be used by employers and taxpayers to report essential information for the collection and distribution of Local Earned Income Taxes
to the local EIT collector. This form must be used by employers when a new employee is hired or when a current employee notifies employer
of a name or address change. Use the Address Search Application at dced.pa.gov/Act32 to determine PSD codes, EIT rates,
and tax collector contact information.
NAME (Last Name, First Name, Middle Initial) SOCIAL SECURITY NUMBER
STREET ADDRESS (No PO Box, RD or RR)
ADDRESS LINE 2
CITY STATE ZIP CODE DAYTIME PHONE NUMBER
CERTIFICATION
SIGNATURE OF EMPLOYEE DATE (MM/DD/YYYY)
PHONE NUMBER EMAIL ADDRESS
MUNICIPALITY (City, Borough or Township)
COUNTY RESIDENT PSD CODE TOTAL RESIDENT EIT RATE
EMPLOYER INFORMATION – EMPLOYMENT LOCATION
EMPLOYER BUSINESS NAME (Use Federal ID Name) EMPLOYER FEIN
STREET ADDRESS WHERE ABOVE EMPLOYEE REPORTS TO WORK (No PO Box, RD or RR)
ADDRESS LINE 2
CITY STATE ZIP CODE PHONE NUMBER
MUNICIPALITY (City, Borough or Township)
COUNTY WORK LOCATION PSD CODE WORK LOCATION NON-RESIDENT EIT RATE
For information on obtaining the appropriate MUNICIPALITY (City, Borough, Township), PSD CODES, and EIT (Earned Income Tax) RATES,
please refer to the Pennsylvania Department of Community & Economic Development website:
dced.pa.gov/Act32
CLGS-32-6 (05/17)
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.
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