Notice Of Intent To File Combined Returns And Make Combined Payments Form

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NOTICE OF INTENT TO FILE COMBINED RETURNS 
AND MAKE COMBINED PAYMENTS 
 
DATE:  __________________ 
TO:  ___________________________________________________________ 
FROM:   EMPLOYER NAME__________________________________________ 
                                  FED ID#___________________ 
 
       CORPORATE ADDRESS __________________________________________ 
__________________________________________ 
 
 
        
__________________________________________ 
PSD OF BUSINESS LOCATION WHERE EMPLOYER’S PAYROLL OPERATIONS ARE LOCATED (IF IN STATE) OR 
BUSINESS LOCATION WHERE EMPLOYER IS FILING MONTHLY (IF PAYROLL OPERATIONS ARE OUT OF STATE). 
PSD Name: ______________________________________ 
PSD Code:  _______________ 
 
Please be advised that ____________________________________, is hereby filing this Notice of Intent to File 
Combined Returns and Payments of the Local Earned Income Tax withheld from all employees who are 
employed in the Commonwealth of Pennsylvania with BERKHEIMER TAX ADMINISTRATOR, 50 NORTH 
SEVENTH STREET, BANGOR, PA 18013, Tax Officer for the ____________________ County Tax Collection 
District, effective January 1, 2012.  
 
As part of this decision, EMPLOYER understands and commits to the following requirements: 
1. EMPLOYER shall deduct the correct tax rate for each employee who is employed in any of the EMPLOYER’S 
Pennsylvania work locations from their wages.  The tax rate to be withheld will be the greater of the 
employee’s resident tax or the non‐resident rate of the employee’s work location, as reflected in the 
official register maintained by the Pennsylvania Department of Community and Economic Development. 
2. Within thirty (30) days of the end of each month, EMPLOYER shall file a return and pay the amount of 
income taxes deducted during the preceding calendar month from all employees employed within the 
Commonwealth of Pennsylvania. 
3. The return must be filed and paid electronically through our e‐file portal and must include the Social 
Security number, name, address, wages paid, tax withheld, and resident  PSD code for each employee. 
Also included on the return shall be all necessary Employer information including Federal ID Number, 
Name, Address and PSD in which business is located.  EMPLOYER agrees to submit their electronic file 
using one of the following filing formats:  CSV File Format, Federal File Format, or the Pennsylvania 
Standard File Format.  

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