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 supplemental 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:
,
,
.
0 0
,
,
.
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: =$
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