Earned Income Tax Exemption Form - City Of Pittsburgh

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Print out form and give complete copy to your employer
City of Pittsburgh, PA
Department of Finance
Earned Income Tax Division
City-County Building
Pittsburgh, PA 15219
(412) 255-8822
To Employer: _____________________________
Address: ________________________________
________________________________________
I hereby inform you that I became a resident of ___________________________ on
____/____/____ and pay an Earned Income Tax of _____% to that municipality and/or
School District. I am not liable for City and/or School District of Pittsburgh Earned
Income Tax.
I certify that this employee is registered as taxpayer in my
jurisdiction, and is paying the Earned Income Tax to his or her place of residence.
Employee: _____________________________
Address: _________________________________________________
__________________________________________________________
Local Tax Collector
Tax Collector’ s Signature: ____________________________ Date: ___________
S.S #: ______________
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