I I I I I I I
CLGS-32-6 (8-11)
RESIDENCY CERTIFICATION FORM
Local Earned Income Tax Withholding
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.
EMPLOYEE INFORMATION - RESIDENCE LOCATION
NAME (Last Name, First Name, Middle Initial) SOCIAL SECURITY NUMBER
STREET ADDRESS (No PO Box, RD or RR)
SECOND LINE OF ADDRESS
CITY STATE ZIP CODE DAYTIME PHONE NUMBER
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)
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
CERTIFICATION
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.
SIGNATURE OF EMPLOYEE DATE (MM/DD/YYYY)
PHONE NUMBER EMAIL ADDRESS
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
Ursinus College
2
3
1
1
7
7
9
3
0
601 E. Main Street
Collegeville
PA
19426
610 409-3000
Collegeville
4
6
1
2
0
1
1.00%
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