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EMPLOYEE INFORMATION – RESIDENCE LOCATION

NAME (Last Name, First Name, Middle Initial)

SOCIAL SECURITY NUMBER

Address

STREET ADDRESS (No PO Box, RD or RR) ADDRESS LINE 2 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

Address

STREET ADDRESS WHERE ABOVE EMPLOYEE REPORTS TO WORK (No PO Box, RD or RR) ADDRESS LINE 2 CITY STATE ZIP CODE

PHONE NUMBER

MUNICIPALITY (City, Borough or Township)

COUNTY

Work Location Code

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.

Consent

I agree to the privacy policy.

DATE (MM/DD/YYYY)

PHONE NUMBER

EMAIL ADDRESS