Certificate Of Residence Form
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1CERTIFICATE OF RESIDENCE
PRINT OR TYPE ONLY
INCOME TAX OFFICER
EMPLOYEE'S FULL NAME: (Last, First, Middle)
SOCIAL SECURITY NO.
OFFICE USE ONLY
Verified by:________________ Date: ______________
ADDRESS:
Street or RD
Post Office
State
Zip Code
Remarks: ___________________________________
VOTING RESIDENCE: (Name of City, Borough or Township)
County
State
__________________________________________
__________________________________________
DATE MOVED IN:
EARNED INCOME RATE AT
%
If so, Name of Taxing District
INSTRUCTIONS
RESIDENT DISTRICT (If Any)
This form must be completed in full by all employees
working in the Taxing District in order to establish
EMPLOYER'S NAME:
residence and tax liability. Persons failing to complete
form will be considered residents of the taxing district
ADDRESS:
Street or RD
Post Office
State
Zip Code
until such form is properly completed.
EMPLOYERS: Retain a copy of each employee for
NAME OF MUNICIPALITY IN
City
Borough or Township
County
WHICH PLANT IS LOCATED:
review by tax office. Where questions arise contact tax
office for a specific ruling.
CERTIFICATION: I certify that the information contained hereon is true and correct to the best of my knowledge and belief.
SIGNATURE: ____________________________________________
DATE: ___________________
PHONE: __________________________
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