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*COPY*
1. Gross Compensation as Reported on W-2(s). (Enclose W-2(s)) .........................
2. Unreimbursed Employee Business Expenses. (Enclose PA Schedule UE) ...........
3. Other Taxable Earned Income * ..........................................................................
4. Total Taxable Earned Income (Subtract Line 2 from Line 1 and add Line 3)....
5. Net Profit (Enclose PA Schedules*) ......................................................................
6. Net Loss (Enclose PA Schedules*) ........................................................................
7. Total Taxable Net Profit (Subtract Line 6 from Line 5.  If less than zero, enter zero)......
8. Total Taxable Earned Income and Net Profit (Add Lines 4 and 7) .........................
9. Total Tax Liability (Line 8 multiplied by )..........................
10. Total Local Earned Income Tax Withheld (MAY NOT EQUAL W-2 - SEE INSTRUCTIONS)*
11.Quarterly Estimated Payments/Credit From Previous Tax Year.........................
12. Out of State or Philadelphia credits* (include supporting documentation)…....
13. TOTAL PAYMENTS and CREDITS (Add lines 10 through 12) .....................
14. Refund IF MORE THAN $1.00, enter amount (or select option in 15) ....................
15. Credit Taxpayer/Spouse (Amount of Line 14 you want as a credit to your account).........
16. EARNED INCOME TAX BALANCE DUE (Line 9 minus Line 13) ....................
17. Penalty after due date (multiply line 16 by 0 x number of months (or a fraction of) late)..
18. Interest after due date (multiply line 16 by x number of months (or a fraction of) late).
19. TOTAL PAYMENT DUE (Add Lines 16, 17, and 18) Payable to HAB-EIT .........
T
AXPAYER ANNUAL LOCAL EARNED INCOME TAX RETURN
RESIDENT JURISDICTION:
The calculations reported in the first column MUST pertain to the name printed in
the column, regardless of whether the husband or wife appears first.
Combining income is NOT permitted.
Enter spouse’s Social Security #
Enter Social Security #
*DCEDF1*
ENTER SPOUSE’S NAME
E
XTENSION
ONLY USE BLACK OR BLUE INK TO COMPLETE THIS FORM
DO NOT STAPLE
A
MENDED RETURN
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0 0
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rrie
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Jo
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tly Ma
rrie
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ly
disabled student
deceased military
homemaker retired
unemployed
If you had NO EARNED INCOME,
check the reason why:
disabled student
deceased military
homemaker retired
unemployed
If you had NO EARNED INCOME,
check the reason why:
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*See Instructions
F-1
F1
NON-TAXABLE S-Corp earnings check this box:
Credit to next year Credit to spouse
Y
ou are entitled to receive a written explanation of your rights with regard to the audit, appeal, enforcement, refund and
c
ollection of local taxes by calling Berkheimer at 610-599-3182. Or, you can visit our website at www.hab-inc.com.
Berkheimer is not the appointed tax hearing officer for your taxing district and will not accept any petitions for appeal.
P
etitions for appeal must be filed with the appropriate appeals board for your County. Berkheimer can provide you with
the proper procedures and forms necessary to file an appeal with the appeals board for your Tax Collection District.
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Did you move during the year?  If yes, check here and see back of form.
P
O Box 25130
Lehigh Valley, PA 18002-5130
TAX YEAR
DAYTIME PHONE NUMBER RESIDENT PSD CODE
YOUR SIGNATURE SPOUSE’S SIGNATURE (If Filing Jointly) DATE (MM/DD/YYYY)
PREPARER’S PRINTED NAME & SIGNATURE PHONE NUMBER
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.
To file online, visit www.berk-e.com
●
There will be a $29.00 fee for returned payments.
●
Penalty, interest and additional fees will be assessed if no payment is enclosed for tax due at time of filing.
091619 dced-f1-19
(i
nternal)
F
M
If you calculate a refund due, you may be denied. Please see Line 10 instructions.
Please do not submit copies of this form.  
ACCOUNT #
AB
WEB
Name
Address
C
ity
State
&
Zip
A NOTE FOR RETIRED AND/OR SENIOR CITIZENS
If you are retired and are no longer receiving wages or income from a business you may not owe an earned income tax. Social security payments,
payments from a qualified pension plan and interest and/or dividends accrued from bank accounts and/or investments are not subject to the local earned
income tax.
If you received a local earned income tax form and are retired with no earned income, check the appropriate box on the front of this form and return it to us.
LOCAL WORKSHEET (Moved During the Year) - Use this for Social Security Number A. For Spouse's (Social Security Number B on front of form) move information
or for additional space for Social Security Number A, download an additional form from www.berk-e.com.
NON-RECIPROCAL STATE WORKSHEET - See Instructions for line 12
EARNED INCOME: Taxed in other state as shown on the state tax return.
Enclose a copy of state return or credit will be disallowed.............................................................................................. (1) __________________
Local tax rate as specified in instructions for line 12 ........................................................................................................ X __________________
(2) __________________
Tax Liability Paid to other state(s) .......................................................................................... (3)____________________
PA Income Tax (line 1 x PA Income Tax rate for year being reported) .................................. (4)____________________
CREDIT to be used against Local Tax
(Line 3 minus line 4) On line 12 enter this amount
or the amount on line 2 of worksheet, whichever is less. (If less than zero, enter zero) ............................ (5) ________________
S-CORPORATION PROFIT/LOSS REPORT - Use this if you checked the box on line 5 on the front of this return.
To avoid future correspondence add any s-corporation profits or losses
that you reported on your PA-40 return in these boxes.
TAXPAYER A: TAXPAYER B:
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0 0
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,
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0 0
DATES LIVING AT EACH ADDRESS
STREET ADDRESS, CITY, STATE, ZIP
TWP OR BORO
COUNTY
EARNED INCOME TAX WITHHELD WORKSHEET
Complete this worksheet for line 10 on the front of this return if you work in an area where the non-resident tax exceeds your home resident tax rate.
(1) (2)
(3) Home Location (4) Work Location
(5)
(6) Disallowed (7) Credit Allowed
Local Wages Tax Withheld Resident Rate Non-Resident Rate Col 4 minus Col 3 Withholding Credit For Tax Withheld
(W2 box 16 or 18) (W2 box 19) (See page 1, line 9) (See Instructions) (if less than 0 enter 0) (Col 1 x Col 5) (Col 2 - Col 6)
Example $10,000 $130 1.25% 1.30% 0.05% $5.00 $125.00
1.
2.
3.
TOTAL - Enter this amount on Line 10
LINES 5 & 6: NET PROFITS/NET LOSSES FROM BUSINESS:
Use line 5 for profit and line 6 for loss. DOCUMENTATION REQUIRED: 1099(s), Phila BIRT/NPT, PA schedules C, E, F, or K-1 must be enclosed
(photocopies are accepted).
PSD CODE
1
2
3
INCOME PRORATION - ADDRESS 1 for Social Security Number A on front of form
Local Income Divided by 12 Multiply by # of
Months at Address 1
Total Income Withholding Divided by 12 Multiply by # of
Months at Address 1
Total Withholding
Employer 1 $ ÷ 12 = x =$ $ ÷ 12 = x =$
Employer 2 $ ÷ 12 = x =$ $ ÷ 12 = x =$
Employer 3 $ ÷ 12 = x =$ $ ÷ 12 = x =$
Subtotal Income at Address 1 for all Employers: =$ Subtotal Withholding at Address 1 for all Employers: =$
INCOME PRORATION - ADDRESS 2 for Social Security Number A on front of form
Local Income Divided by 12 Multiply by # of
Months at Address 2
Total Income Withholding Divided by 12 Multiply by # of
Months at Address 2
Total Withholding
Employer 1 $ ÷ 12 = x =$ $ ÷ 12 = x =$
Employer 2 $ ÷ 12 = x =$ $ ÷ 12 = x =$
Employer 3 $ ÷ 12 = x =$ $ ÷ 12 = x =$
Subtotal Income at Address 2 for all Employers: =$ Subtotal Withholding at Address 2 for all Employers: =$
INCOME PRORATION - ADDRESS 3 for Social Security Number A on front of form
Local Income Divided by 12 Multiply by # of
Months at Address 3
Total Income Withholding Divided by 12 Multiply by # of
Months at Address 3
Total Withholding
Employer 1 $ ÷ 12 = x =$ $ ÷ 12 = x =$
Employer 2 $ ÷ 12 = x =$ $ ÷ 12 = x =$
Employer 3 $ ÷ 12 = x =$ $ ÷ 12 = x =$
Subtotal Income at Address 3 for all Employers: =$ Subtotal Withholding at Address 3 for all Employers: =$
dced-f1-b19 100119
TO
TO
TO
I2176 103018
A. GENERAL INSTRUCTIONS
1. WHEN TO FILE: This return must be completed and filed by all persons subject to the tax on or before the federal filing date, which
is normally April 15 (unless the 15th is a Saturday or Sunday then file the next business day), regardless of whether or not tax is due.
If you file a Federal or State Application for Extension, check the extension box on the front of the form and send this form along with
your estimated payment by the federal filing date. If you use a professional tax preparer verify if you are responsible to submit your
final return or if it was submitted for you.
2. WHERE TO FILE: Remit to the address printed on the tax return or see if you are eligible to file online at www.hab-inc.com.
3. EFFECTIVE DATES: January 1 through December 31, unless otherwise noted on your Local Earned Income Tax Return.
4. AMENDED RETURN: If a taxpayer amends his federal income tax return, an amended Local Earned Income Tax Return must
also be filed with this office. Check the Amended Return box on the front of the form.
5. RECEIPT / COPY: Your cancelled check is sufficient proof of payment.
6. PENALTY AND INTEREST: If for any reason the tax is not paid when due, Penalty and Interest will be charged. Any late, incorrect
filing or payment may result in fees and penalties including a 10% Delinquent Account Servicing fee.
7. ROUND OFF CENTS to the nearest whole dollar. Do not include amounts under 50 cents and increase amounts from 50 to 99
cents to the next dollar amount.
8. USE BLACK OR BLUE INK ONLY WHEN COMPLETING THIS FORM. DO NOT USE RED INK.
9. Do not staple documents or paper to form.
10. Please submit the original form only, do not submit copies. If additional blank copies are needed, please go to www.hab-inc.com.
B. REGULATIONS/LINE BY LINE INSTRUCTIONS
LINE 1: GROSS EARNINGS FOR SERVICES RENDERED
DOCUMENTATION REQUIRED: W-2(S) must be enclosed (photocopies are accepted).
LINE 1: TAXABLE INCOME INCLUDES: Salaries; Wages; Commissions; Bonuses; Tips; Stipends; Fees; Incentive
Payments; Employee Contributions to Retirement Accounts; Compensation Drawing Accounts (if amounts received as a
drawing account exceed the salaries or commission earned, the tax is payable on the amounts received. If the employee
subsequently repays to the employer any amounts not in fact earned, the tax shall be adjusted accordingly); Benefits accruing
from the employment, such as: Annual Leave, Vacation, Holiday, Separation, Sabbatical Leave; Compensation received in
the form of property shall be taxed at its fair market value at the time of receipt; Jury Duty Pay; Military Pay for Services
Other than Active Duty; Sick Pay (if employee received a regular salary during period of sickness or disability by virtue of his
agreement of employment); Taxes assumed by the Employer.
NON-TAXABLE INCOME INCLUDES: Social Security Benefits; Unemployment Compensation; Pensions; Public Assistance;
Death Benefits; Gifts; Interest; Dividends; Boarding and Lodging to employees for convenience of employer; Lottery Winnings;
Supplementary unemployment benefits (sub pay); Capital Gains (Capital losses may not be used as a deduction against
other taxable income); disability benefits (Periodical payments received by an individual under a disability insurance plan.);
Active Military Services; personal use of company cars; cafeteria plans; and clergy housing allowance. Some forms of
payments from Individual Retirement Programs, such as Keogh, Tax Shelter Annuity, IRA, and 401K are not taxable. Taxpayer
should refer to the PA Department of Revenue regulations regarding taxable compensation.
LINE 2: ALLOWABLE EMPLOYEE BUSINESS EXPENSES
DOCUMENTATION REQUIRED: Pennsylvania form PA-UE must be enclosed (photocopies are accepted).
LINE 3: OTHER TAXABLE EARNED INCOME: Include income from work or services performed which has not been included on
line 1or line 5. Do not include interest, dividends or capital gains.
LINE 4: TOTAL TAXABLE EARNED INCOME: Subtract line 2 from line 1 and add line 3.
LINES 5 & 6: NET PROFITS/NET LOSSES FROM BUSINESS: Use line 5 for profit and line 6 for loss. DOCUMENTATION
REQUIRED: 1099(s), Phila BIRT/NPT, PA schedules C, E, F, or K-1 must be enclosed (legible photocopies are accepted).
RULE: A taxpayer may NOT offset a business loss against wages and other compensation (W-2 earnings -- line 1). "Pass-
through" income from an S-Corporation is NOT taxable and loss is not deductible. A taxpayer may offset a loss from one
business entity against a net profit from another business entity.
LINE 7: TOTAL TAXABLE NET PROFIT: Subtract line 6 from line 5; if less than zero, enter zero.
LINE 8: TOTAL TAXABLE EARNED INCOME AND NET PROFIT: Add lines 4 & 7.
LINE 9: TAX LIABILITY: Multiply line 8 by the tax rate printed on the tax return. For example, if 1% use .01, if 1/2% use .005. If you
don’t know your rate, contact your local earned income tax collector where you live or visit www.newPA.com to find your rate.
LINE 10: EARNED INCOME TAX WITHHELD: If you work in an area that taxes non-residents at a higher rate than the resident rate
where you live, you may not be able to claim the entire amount of tax withheld on your W-2's
. If this is the case complete
the worksheet on the back of the Final Return Form to calculate the amount of income tax withheld to enter on Line 10 of the
Final Return. If this is not the case then combine the amount of tax withheld as reported in box 19 of your W-2's and report
that amount on Line 10 of the Final Return. To determine if you work in an area that has a Non-Resident Tax Rate that
exceeds the resident rate where you live, contact your employer or visit: http://munstats.pa.gov/Public/FindLocalTax.aspx
LINE 11: QUARTERLY ESTIMATED PAYMENTS/CREDITS FROM PREVIOUS TAX YEAR: List any quarterly estimated payments
made to date for appropriate filing year. Do not include any penalty and interest amounts that may have been made with the
quarterly payments. Also, include tax credit from the previous tax year.
NOTE: Taxpayers who expect to have net profits or wages not subject to withholding must report and timely pay quarterly
estimated tax payments. Quarterly Estimated form DQ-1 is used to report the income and pay the tax each quarter and
credit may be claimed on this line for any such advance payments of tax
LOCAL EARNED INCOME TAX RETURN
LINE 12: : OUT-OF-STATE OR PHILADELPHIA CREDITS
GENERAL RULES APPLICABLE TO ALL LINE 12 CREDITS: (1) Credits for income taxes paid to other states must first be
used against your Pennsylvania state income tax liability; any credit remaining thereafter may be used against your local earned
income tax liability. (2) Credits for income taxes paid to political subdivisions located outside of Pennsylvania or for wage taxes
paid to Philadelphia may be taken directly against your local earned income tax liability. (3) In calculating your credit for income
taxes paid to another state or to a political subdivision, note that the same items of income must be subject to both your local
earned income tax and the out-of state tax. (4) No credit for income taxes paid to another state or political subdivision
may exceed your total local earned income tax liability.
CREDIT FOR TAXES PAID TO OTHER STATES: You may take a credit based upon the gross earnings taxed both in
another state and in Pennsylvania that is in excess of the Pennsylvania state personal income tax rate. THIS CREDIT WILL
BE DISALLOWED IF THE NON-RESIDENT STATE RETURN AND THE DOCUMENT SHOWING STATE INCOME TAX
WITHHELD ARE NOT PROVIDED (W-2, K-1, Etc.). No credits are given for state income taxes paid to states that
reciprocate with the Commonwealth of Pennsylvania. These states are: Maryland, New Jersey, Ohio, Virginia, West Virginia,
and Indiana.
EXAMPLE: Taxpayer earned wages of $10,000.00 in Delaware and paid an income tax liability to that state of $317.00.
Assuming the current Pennsylvania state tax rate is 3.07% for the tax year in question, since the $317.00 exceeds 3.07% (PA
Tax) amount of $307.00 by $10.00, the $10.00 may be credited against your local income tax.
Gross Income (1) $10,000.00
Local tax rate as specified on front of the form x .01
(2) 100.00
Tax paid to Delaware (3) 317.00
PA Income Tax (3.07% x $10,000.00) (4) 307.00
Credit to be used against Local Tax
(Line 3 minus Line 4)
On Line 12 of the tax return, enter this amount (5) 10.00
or the amount on Line 2 of worksheet,
whichever is less
If all your wages or gross earnings are subject to Delaware State Income Tax (not PA), use the above example to complete
your tax obligation on Worksheet located on the reverse side of the tax return. If you had earned income NOT taxed by Delaware,
this income would be subject to the earned income tax effective in your district and must be shown separately on the Local
Earned Income Tax Return. You may not use any tax paid to another state as credit on earnings outside the other state.
CREDIT FOR TAXES PAID TO POLITICAL SUBDIVISIONS OUTSIDE OF PENNSYLVANIA: You may take a credit based
upon the gross earnings taxed in both another political subdivision and in your home taxing district in Pennsylvania. THIS
CREDIT WILL BE DISALLOWED IF THE FOREIGN CITY RETURN AND OR YOUR W-2 FORM SHOWING CITY INCOME
TAX WITHHELD IS NOT PROVIDED.
CREDIT FOR TAXES PAID TO PHILADELPHIA: You may use any wage taxes paid to Philadelphia as a credit on wages, salaries
and commissions, etc., or net profits earned outside of Philadelphia. A COPY OF YOUR W-2 AND/OR VERIFICATION OF TAXES
PAID MUST BE ENCLOSED WITH THE FORM OR CREDIT WILL BE DISALLOWED. No refunds or credits will be allowed for
any overpayment made to Philadelphia.
LINE 13: TOTAL PAYMENTS AND CREDITS: Enter the sum of lines 10, 11 & 12.
LINE 14: REFUND: Before calculating a refund, ensure that you have followed the instructions for Line 10 accurately. Most
refund requests are denied because the amount of money withheld is claimed incorrectly. If tax due (line 9) is less than your
credits (line 13), enter amount of refund. If you have an overpayment of taxes in excess of $1.00, you may elect to receive
a refund or take as a credit against next year's tax liability. A 1099 will be issued to the Federal Government for any credit or
refund in excess of $10.00.
LINE 15: CREDIT: If tax (line 9) is less than your credits (line 13) enter amount of credit and check the applicable box for credit to
spouse or credit to next year. A 1099 will be issued to the Federal Government for any credit or refund in excess of $10.00.
LINE 16: AMOUNT OF TAX DUE: If tax (line 9) is larger than your credits (line 13), enter amount of tax due. If less than$1.00, ENTER ZERO.
LINE 17 & 18: INTEREST AND PENALTIES: If for any reason the tax is not paid when due, interest and an additional penalty
of the unpaid tax for each month shall be added and collected. Additional costs will be charged for any return received after
the due date.
LINE 19: TOTAL AMOUNT DUE: The sum of lines 16, 17 & 18. OMIT IF LESS THAN $1.00. Make Checks Payable to HAB-EIT.
No cash payments accepted.
NOTE: All accounts are subject to audit and review. Local or city copy of W-2 and/or supporting schedules must be enclosed with
tax return. (Photocopies of W-2s and schedules are accepted).
HAB FI Payment
PO Box 25158
Lehigh Valley, PA 18002-5158
HAB FI None
PO Box 25159
Lehigh Valley, PA 18002-5159
HAB FI Refund
PO Box 25160
Lehigh Valley, PA 18002-5160
SUBMIT YOUR RETURN
For Returns with Payments:
For Returns with No Payment,
No Refund:
For Returns with Refunds:
I2176 103018
_____
_____
_____
_____
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