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Certificate Of Residence

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DCED-CLGS-06 (1-11)

COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF COMMUNITY & ECONOMIC DEVELOPMENT

GOVERNOR’S CENTER FOR LOCAL GOVERMENT SERVICES

LOCAL EARNED INCOME TAX

RESIDENCY CERTIFICATION FORM

TO E M P L O Y E R S / TA X PAY E R S :

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, FIrst, Middle Initial)

SOCIAL SECURITY NUMBER

FIRST LINE OF ADDRESS (If PO Box, please include actual street address)

SECOND LINE OF ADDRESS

CITY

STATE

ZIP CODE

DAYTIME PHONE NUMBER

MUNICIPALITY (City, Borough, Township)

COUNTY