Residency Information Form - 2009 printable pdf download

Residency Information Form - 2009

WEST SHORE TAX BUREAU

PO BOX 656 CAMP HILL PA 17001-0656

RESIDENCY INFORMATION FORM

THIS FORM IS TO BE USED BY EMPLOYERS TO REPORT ESSENTIAL INFORMATION. THE FORM

SHOULD BE USED WHEN HIRING NEW EMPLOYEES OR WHEN A CURRENT EMPLOYEE

NOTIFIES THE EMPLOYER OF A NAME AND/OR ADDRESS CHANGE. WHEN THE FORMS ARE

COMPLETE THE INFORMATION SHOULD BE SENT TO THE EMPLOYER DEPARTMENT OF THE

WEST SHORE TAX BUREAU. FORMS MAY BE SENT TO THE BUREAU AS COMPLETED OR SENT

WITH THE QUARTERLY DETAIL REPORT. THESE FORMS MAY BE REPRODUCED AND ALSO

MAY BE OBTAINED FROM OUR WEBSITE:

_____ ________

SOCIAL SECURITY NUMBER _________

_________________________________________________________________________

RESIDENT’S NAME

LAST

FIRST

MAILING ADDRESS _______________________________________________________________________________________

* STREET ADDRESS *

PO BOX NUMBER

_____________________________________________________________________________________________________________

CITY/TOWN

STATE

ZIP

RESIDENT’S MUNICIPALITY _______________________________________________________________________________

BORO/ TOWNSHIP/ CITY

COUNTY

RESIDENT’S SCHOOL DISTRICT_____________________________________________________________________________

RESIDENT’S MOVE IN DATE _____________________________________

SIGNATURE __________________________________________________________________DATE______________________

*PLEASE NOTE: JUST PO BOX NUMBER IS NOT ACCEPTABLE. MUST INCLUDE ACTUAL

STREET ADDRESS!

(Revised 7/9/2009 SD)

Residency Information Form - 2009