OWNER NAME 1 (First Name, Last Name)
EMPLOYER LOCAL SERVICES TAX REGISTRATION
EMPLOYER INFORMATION
SIGNATURE DATE (MM/DD/YYYY)
FEDERAL EMPLOYER ID NUMBER DATE BUSINESS STARTED (Month and Year) NUMBER OF EMPLOYEES (Include Full and Part Time)
EMPLOYER BUSINESS NAME (Use Federal ID Name)
E
MPLOYER BUSINESS LOCATION (Street address within PA - NO PO Box, RD or RR)
SECOND LINE OF ADDRESS
CITY OR POST OFFICE
STATE ZIP
EMPLOYER MAILING ADDRESS (Address where all forms are to be sent)
SECOND LINE OF ADDRESS
CITY OR POST OFFICE
STATE ZIP
CORRECT TAXING JURISDICTION (Name of Township or Borough where business is located)
BUSINESS PHONE NUMBER E-MAIL ADDRESS
PRIMARY NATURE / OPERATION OF BUSINESS
I HEREBY CERTIFY THAT ALL INFORMATION AND STATEMENTS HEREIN ARE TRUE AND CORRECT.
To comply with Act 511 of The Pennsylvania State Legislature (and the law in your local taxing district), you are
required to provide the following information. All information will be held in strict confidence.
OWNER NAME 2 (First Name, Last Name)
PAYROLL CONTACT NAME (First Name, Last Name)
PO Box 21570
Lehigh Valley, PA 18002
You are entitled to receive a written explanation of your rights with regard to the audit,
a
ppeal, enforcement, refund and collection of local taxes by calling Berkheimer at
610-599-3182. Or, you can visit our website at www.hab-inc.com.
B
erkheimer is not the appointed tax hearing officer for your taxing district and will not
accept any petitions for appeal. Petitions for appeal must be filed with the appropriate
a
ppeals 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
C
ollection District.
PSD
*LSTR*
LSTR
Please complete this form and return to our office at:
Berkheimer Tax Innovations
PO Box 21570
Lehigh Valley, PA 18002
WEB
Name
Address
C
ity
State
&
Zip
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signature
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