Form F-1 - Taxpayer Annual Local Earned Income Tax Return Page 2

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TAXPAYER A:

f1-b-2014

0 0

S-CORPORATION PROFIT/LOSS REPORT

To avoid future correspondence, please report any S Corporation

TAXPAYER B

Pass-Through profits (losses) that were reported on your PA 40 Return.

0 0

LOCAL WORKSHEET (Moved During the Year)

PART YEAR RESIDENT

Residence #1 ____________________ Dates ________ to ________ Length of Time______________

Residence #2 ____________________ Dates ________ to ________ Length of Time______________

INCOME PRORATION ( _____________________________________________________________________ )

Residence # 1 COMPLETE ADDRESS

Employer # 1 ___________________

Local Income $ _______________ / ____________ X _______________________ = ________________

# of months at this residence

Withholding $ _______________ / ____________ X _______________________ = ________________

# of months at this residence

Employer # 2 ___________________

Local Income $ _______________ / ____________ X _______________________ = ________________

# of months at this residence

Withholding $ _______________ / ____________ X _______________________ = ________________

# of months at this residence

Residence #1

Total Income ____________________ Total Withholding ____________________

INCOME PRORATION ( _____________________________________________________________________ )

Residence # 2 COMPLETE ADDRESS

Employer # 1 ___________________

Local Income $ _______________ / ____________ X _______________________ = ________________

# of months at this residence

Withholding $ _______________ / ____________ X _______________________ = ________________

# of months at this residence

Employer # 2 ___________________

Local Income $ _______________ / ____________ X _______________________ = ________________

# of months at this residence

Withholding $ _______________ / ____________ X _______________________ = ________________

# of months at this residence

Residence #2

Total Income ____________________ Total Withholding ____________________

LINES 5 & 6: NET PROFITS/NET LOSSES FROM BUSINESS: Use line 5 for profit and line 6 for loss.

DOCUMENTATION REQUIRED: 1099(s), Phila BIRT/NPT, PA schedules C, E, F, or K-1 must be enclosed (photocopies are accepted).

LINE 10: LOCAL EARNED INCOME TAX WITHHELD WORKSHEET

(Complete worksheet if you work in an area where the non-resident tax rate exceeds your home resident rate)

(1)

(2)

(5)

(3) Home Location

(4) Work Location

(6) Disallowed

(7) Credit Allowed

Local Wages

Tax Withheld

Resident Rate

Non-Resident Rate

Col 4 minus Col 3

Withholding Credit

For Tax Withheld

(W2 box 16 or 18)

(W2 box 19)

(See page 1, line 9)

(See Instructions)

(if less than 0 enter 0)

(Col 1 x Col 5)

(Col 2 - Col 6)

$10,000

$130

1.25%

1.30%

0.05%

$5.00

$125.00

Example:

TOTAL - Enter this amount on Line 10

NON-RECIPROCAL STATE WORKSHEET

(See Instructions line 12)

EARNED INCOME: Taxed in other state as shown on the state tax return.

Enclose a copy of state return or credit will be disallowed ..........................................................................................................

(1)______________________

Local tax 1% or Act 511 portion of rate

......

....................................................................................................................................

X ______________________

(2)______________________

Tax Liability Paid to other state(s) ....................................................................................................

(3) ____________________

PA Income Tax (line 1 x PA Income Tax rate for year being reported) ............................................

(4) ____________________

CREDIT to be used against Local Tax

(Line 3 minus line 4) On line 12 enter this amount

or the amount on line 2 of worksheet, whichever is less. (If less than zero, enter zero)....................................

(5) ____________________

**Additional Addresses:

DATES LIVING AT EACH ADDRESS

ADDRESS

TWP OR BORO

COUNTY

You are entitled to receive a written explanation of your rights with regard to the audit, appeal, enforcement, refund and collection of local taxes by calling Berkheimer at 610-599-3139,

during the hours of 8:00 a.m. through 4:00 p.m., Monday through Friday. Or, you can visit our website at

Berkheimer is not the appointed tax hearing officer for your taxing district and will not accept any petitions for appeal. Petitions for appeal must be filed with the appropriate appeals

board for your County. Berkheimer can provide you with the proper procedures and forms necessary to file an appeal with the appeals board for your Tax Collection District.

A NOTE FOR RETIRED AND/OR SENIOR CITIZENS

IF YOU ARE RETIRED AND ARE NO LONGER RECEIVING A SALARY, WAGES OR INCOME FROM A BUSINESS, YOU MAY NOT OWE AN EARNED INCOME TAX.

SOCIALSECURITY PAYMENTS, PAYMENTS FROMAQUALIFIED PENSION PLANAND INTERESTAND/OR DIVIDENDSACCRUED FROM BANKACCOUNTSAND/OR

INVESTMENTS ARE NOT SUBJECT TO THE LOCAL EARNED INCOME TAX.

IF YOU RECEIVED A LOCAL EARNED INCOME TAX FORM AND ARE RETIRED WITH NO EARNED INCOME, PLEASE CHECK THE APPROPRIATE BOX ON THE

FORM AND RETURN.

IF YOU STILL RECEIVE WAGES FROM A PART-TIME EMPLOYER OR BUSINESS, YOU WILL NEED TO FILE AND PAY THE EARNED INCOME TAX.