DCED-CLGS-06 (1-11)	COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF COMMUNITY & ECONOMIC DEVELOPMENT GOVERNOR'S CENTER FOR LOCAL GOVERNMENT SERVICES
	LOCAL EARNED INCOME TAX RESIDENCY CERTIFICATION FORM

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.

NAME (Last, First, Middle Initial) {{Last_Name}} {{First_Name}} {{Middle_Initial}}			SOCIAL SECURITY NUMBER {{SSN}}
FIRST LINE OF ADDRESS (If PO Box, please indicate actual street address) {{Residence_Address}}
Second LINE OF ADDRESS {{Residence_Address_2}}
CITY {{Residence_City}}	STATE {{Residence_State}}	ZIP CODE {{Residence_Zip}}	DAYTIME PHONE NUMBER {{Residence_Phone}}
MUNICIPALITY (City, Borough, Township) {{Residence_Municipality}}
COUNTY {{Residence_County}}	PSD CODE {{Residence_PSD}}	TOTAL RESIDENT EIT RATE