Employers use it when hiring a new employee or when a current employee notifies the employer of a name or address change.

Do I need a notary for the Local Earned Income Tax Residency Certification Form?

No. The employee signs and dates the certification; the form lists no notarized attachment or related step.

Charleroi, PA · Washington County

No notary required

Local Earned Income Tax Residency Certification Form

Employers and taxpayers use this form to report employee residence and workplace details for the collection and distribution of local earned income taxes.

What this form is

This form records an employee’s residence and employer’s employment-location information for the collection and distribution of local earned income taxes. Employers must use it when hiring a new employee or when a current employee reports a name or address change. It requests identifying, address, municipality, county, PSD code, tax-rate, and contact details, plus the employee’s signature and date.

Who needs it

Employers use this form for new employees and when a current employee reports a name or address change.

How to submit it

Submit it to the city department named on the form; check the city website for current contact details.

About notarization

This document is signed without a notary; the employee signs and dates the certification, and the form lists no notarized attachment or related step.

How to submit this form

1
Download The Form
Download the Local Earned Income Tax Residency Certification Form.
2
Complete The Information
Enter the employee’s residence details and the employer’s employment-location information requested on the form.
3
Review And Sign
Complete the municipality, county, PSD code, and tax-rate fields, then have the employee sign and date the certification.
4
Submit To The City
Submit it to the city department named on the form; check the city website for current contact details.

Frequently asked questions

What is the Local Earned Income Tax Residency Certification Form?: It reports employee residence and employer employment-location information for the collection and distribution of local earned income taxes.
Who uses this form?: Employers use it when hiring a new employee or when a current employee notifies the employer of a name or address change.
Do I need a notary for the Local Earned Income Tax Residency Certification Form?: No. The employee signs and dates the certification; the form lists no notarized attachment or related step.
How do I submit the Local Earned Income Tax Residency Certification Form?: Submit it to the city department named on the form; check the city website for current contact details.

Need something notarized?

This Local Earned Income Tax Residency Certification Form doesn’t need a notary — but if you have another Charleroi form that does, a commissioned online notary can help.