TO BE RETURNED TO:
FOR TAX OFFICE
MUNICIPAL & SCHOOL
USE ONLY
MUNICIPAL & SCHOOL
INCOME TAX OFFICE
2790 W FOURTH STREET
EARNED INCOME TAX
WILLIAMSPORT PA 17701
PHONE: (570)601-3980 EXT:33540
QUESTIONNAIRE
FAX: (570)327-0650
TO RESIDENTS OF THE FOLLOWING SCHOOL DISTRICTS:
East Lycoming, Jersey Shore, Loyalsock, Montgomery, Montoursville, Muncy,
South Williamsport & Williamsport
In order to keep our records current and to comply with Act of General Assembly approved December 31, 1965, Act No. 511 or Act 32 of 2008, and
the Tax Resolutions and Ordinances adopted by the respective taxing Districts, the following information is necessary and must be answered fully by
all residents of said Districts. All information will be held in strict confidence.
1. Full Name: ____________________________________________ S.S. # ________________________
Spouse: ________________________________________ Spouse S.S. #: ________________________
2. Resident Address _____________________________________________________________________
County __________________________________ Date You Moved There_______________________
3. Municipality, Borough, or Township __________________ Phone Number_______________________
4. Please List ANY previous addresses Including, Dates at each address and Municipalities.
You may use the back of this form for additional space.
Street Address (No Po Box’s)
Dates at each address
City, State, Zip
Municipality
From:
/
/ 20__
To:
/
/ 20__
From:
/
/ 20__
To:
/
/ 20__
From:
/
/ 20__
To:
/
/ 20__
From:
/
/ 20__
To:
/
/ 20__
5. Name & Address of Employer or Employers (if self employed list trade name & business address)
____________________________________________________
6. Check here if:
Permanently disabled, housewife, retired, etc
Temporarily unemployed
I HEREBY CERTIFY THAT ALL INFORMATION AND STATEMENTS HEREIN ARE TRUE AND CORRECT.
SIGNATURE
DATE ________________________
_____________________________________________________
SPECIAL NOTICE
The Municipal and School Earned Income Tax Office should be notified immediately of any change of address or name.
Reset Form
Submit
QUESTIONNIARE 5/22/2015
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