LOCAL EARNED INCOME TAX
RESIDENCY CERTIFICATION FORM
DCED-CLGS-06 (1-11)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF COMMUNITY & ECONOMIC DEVELOPMENT
GOVERNOR’S CENTER FOR LOCAL GOVERMENT SERVICES
EMPLOYEE INFORMATION - RESIDENCE LOCATION
TO EMPLOYERS/TAXPAYERS:
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.
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.
NAME (Last, FIrst, Middle Initial) SOCIAL SECURITY NUMBER
FIRST LINE OF ADDRESS (If PO Box, please include actual street address)
SECOND LINE OF ADDRESS
CITY STATE ZIP CODE DAYTIME PHONE NUMBER
CERTIFICATION
SIGNATURE OF EMPLOYEE DATE
PHONE NUMBER EMAIL ADDRESS
MUNICIPALITY (City, Borough, Township)
COUNTY PSD CODE TOTAL RESIDENT EIT RATE
EMPLOYER INFORMATION - EMPLOYMENT LOCATION
EMPLOYER NAME (Use Federal ID Name) EMPLOYER FEIN
FIRST LINE OF ADDRESS (
I
If PO Box, please include actual street address)
SECOND LINE OF ADDRESS
CITY STATE ZIP CODE PHONE NUMBER
MUNICIPALITY (City, Borough, Township)
COUNTY PSD CODE MUNICIPAL 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:
www.newPA.com
Select Get Local Gov Support, >Municipal Statistics
