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. Payroll Office Fax Number: 610-683-4881
NAME (Last Name, First Name, Middle Initial) Social Security or Personnel Number
STREET ADDRESS (No PO Box, RD or RR)
MAILING ADDRESS
CITY STATE ZIP CODE
DAYTIME PHONE NUMBER
CERTIFICATION
SIGNATURE OF EMPLOYEE DATE (MM/DD/YYYY)
PHONE NUMBER EMAIL ADDRESS (List Kutztown email address)
MUNICIPALITY (City, Borough or Township) CIRCLE ONE
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)
SECOND LINE OF ADDRESS
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:
www.newPA.com
CLGS-32-6 (8-11)
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.
CITY STATE
ZIP CODE
KU Student ID Number
RESIDENCY CERTIFICATION FORM
LOCAL EARNED INCOME TAX WITHHOLDING
PENNSYLVANIA STATE SYSTEM OF HIGHER EDUCATION - KUTZTOWN UNIVERSITY 2 5 1 6 9 0 6 9 4
15200 KUTZTOWN ROAD
KUTZTOWN PA 19530 610-683-1353
MAXATAWNY TOWNSHIP
BERKS 0 6 1 0 0 6 1.00%
