Affidavit Concerning Residence Form - Lctcb And Matcb printable pdf download

Affidavit Concerning Residence Form - Lctcb And Matcb

Lancaster County Tax Collection Bureau

and

Middletown Area Tax Collection Bureau

299 Hess Blvd., Suite 2, Lancaster, PA 17601-4097

AFFIDAVIT CONCERNING RESIDENCE

Name: _______________________________________________

Phone: _________________

Applicants Soc. Sec. No. _____________________ Spouse's Soc. Sec. No. ______________________

I, the undersigned, being duly sworn according to law, depose and say:

I regularly eat and sleep in a dwelling situated at

________________________________, _________________________ since _____________.

(street)

(city, borough, state)

(date)

I am

___________ married

Location of ______________________________

___________ single

spouse if

______________________________

married

______________________________

I maintain additional dwellings at

________________________________________

I have __________ children who attend school at ____________________________________.

I am registered to vote in _______________________________________________________.

(Political Subdivision - State)

My principal business, occupation or profession is ______________________________ and I

work in _________________________________________.

(Geographical Location)

Employers name, address and telephone number:

_________________________________

In my Federal Income Tax Returns for _______________ and _______________ I listed my

address as __________________________________________________________________.

For the past calendar year I have paid per capita taxes to ______________________________.

(Political Subdivision)

10.

For the past calendar year I have paid Earned Income Tax to __________________________.

11.

For ______________ and ______________ I have filed the following types of Pennsylvania

Income Tax Returns:

__________ Resident

__________ Non-Resident

Affidavit Concerning Residence Form - Lctcb And Matcb