Form Clgs-32-4 - Employer Registration -Local Earned Income Tax Withholding
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1CLGS-32-4 (8-12)
EMPLOYER REGISTRATION
Local Earned Income Tax Withholding
You are entitled to receive a written explanation of your rights with regard to the audit, appeal, enforcement, refund and collection of local taxes. Contact your Tax Officer.
EMPLOYER INFORMATION
EMPLOYER BUSINESS NAME (Use Federal ID Name)
MAIN CORPORATE/BUSINESS LOCATION - STREET ADDRESS (No PO Box, RD or RR)
SECOND LINE OF ADDRESS
CITY
STATE
ZIP
EMPLOYER BUSINESS LOCATION - STREET ADDRESS WITHIN PA (if same as above, leave blank. No PO Box, RD or RR)
SECOND LINE OF ADDRESS
CITY OR POST OFFICE
STATE
ZIP
MUNICIPAL TAXING AUTHORITY (City, Borough or Township) IN WHICH FACILITY OR BUSINESS IS LOCATED
COUNTY
BUSINESS PHONE NUMBER
BUSINESS FAX NUMBER
EMPLOYER PA BUSINESS LOCATION PSD CODE
FEDERAL EIN OR SOCIAL SECURITY #
ORGANIZATION
TYPE OF ORGANIZATION
LLC
Individual Proprietorship
Partnership
Association
Fiduciary
Corporation
PRIMARY NATURE/OPERATION OF BUSINESS
DATE OF INCORPORATION (MM/DD/YYYY)
DATE OPERATION BEGAN AT THIS LOCATION (MM/DD/YYYY)
ACCOUNTING INFORMATION
Does your organization have multiple site locations within Pennsylvania? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
Has your organization opted to remit EIT for employees at all locations to a single Tax Collection District? . . . . . . . . . . .
Yes
No
If YES, please insert 2-digit code for Tax Collection District Selected (choose from list on reverse side) . . . . . . . . . . . . . .
Under penalties of perjury, I (we) declare that I (we) have examined this information, including all accompanying
schedules and statements and to the best of my (our) belief, they are true, correct and complete.
PRIMARY CONTACT INDIVIDUAL (First Name, Last Name)
TITLE
PRIMARY CONTACT PHONE NUMBER
PRIMARY CONTACT EMAIL ADDRESS
SIGNATURE OF PRIMARY CONTACT INDIVIDUAL
DATE (MM/DD/YYYY)
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