Local Earned Income Tax Withholding

1 You are entitled to receive a written explanation of your rights with regard to the audit, appeal, enforcement, refund and collection of Local taxes by contacting your Tax Officer. EMPLOYER REGISTRATIONL ocal Earned Income Tax WithholdingCLGS-32-4 (8-11)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 BUSINESS NAME (Use Federal ID Name)MAIN CORPORATE/BUSINESS LOCATION- STREET ADDRESS (NoPO Box, RD or RR)SECOND LINE OF ADDRESSCITY OR POST OFFICE STATE ZIPEMPLOYER BUSINESS LOCATION- STREET ADDRESS WITHIN PA (if same as above, leave blank.)

2 NoPO Box, RD or RR)SECOND LINE OF ADDRESSCITY OR POST OFFICE STATE ZIPMUNICIPAL TAXING AUTHORITY (City, Borough or Township) IN WHICH FACILITY OR BUSINESS IS LOCATED COUNTY BUSINESS PHONE NUMBER BUSINESS FAX NUMBEREMPLOYER PA BUSINESS LOCATION PSD CODE FEDERAL EIN OR SOCIAL SECURITY #EMPLOYER INFORMATIONORGANIZATIONTYPE OF ORGANIZATION PRIMARY NATURE/OPERATION OF BUSINESS DATE OF INCORPORATION (MM/DD/YYYY) DATE OPERATION BEGAN AT THIS LOCATION (MM/DD/YYYY)

3 PRIMARY CONTACT INDIVIDUAL (First Name, Last Name)TITLE PRIMARY CONTACT PHONE NUMBERPRIMARY CONTACT EMAIL ADDRESSSIGNATURE OF PRIMARY CONTACT INDIVIDUAL DATE (MM/DD/YYYY)LLC Individual Proprietorship Partnership Association Fiduciary CorporationACCOUNTING INFORMATIONDoes your organization have multiple site locations within Pennsylvania? .. Yes NoHas your organization opted to remit EIT for employees at all locations to a single Tax collection District? .. Yes NoIf YES, please insert 2-digit code for Tax collection District Selected (choose from list on reverse side).

4 01 ADAMS TAX collection DISTRICT70 allegheny CENTRAL TAX collection DISTRICT71 allegheny NORTH TAX collection DISTRICT72 allegheny SOUTHEAST TAX collection DISTRICT73 allegheny SOUTHWEST TAX collection DISTRICT03 ARMSTRONG TAX collection DISTRICT04 BEAVER TAX collection DISTRICT05 BEDFORD TAX collection DISTRICT06 BERKS TAX collection DISTRICT07 BLAIR TAX collection DISTRICT08 BRADFORD TAX collection DISTRICT09 BUCKS TAX collection DISTRICT10 BUTLER TAX collection DISTRICT11 CAMBRIA TAX collection DISTRICT12 CAMERON TAX collection DISTRICT13 CARBON TAX collection DISTRICT14 CENTRE TAX collection DISTRICT15 CHESTER TAX collection DISTRICT16 CLARION TAX collection DISTRICT17 CLEARFIELD TAX collection DISTRICT18 CLINTON TAX COLLECTIO DISTRICT19 COLUMBIA TAX collection DISTRICT20 CRAWFORD TAX collection DISTRICT21 CUMBERLAND TAX collection DISTRICT22 DAUPHIN TAX collection DISTRICT23 DELAWARE TAX collection DISTRICT24 ELK TAX collection DISTRICT25 ERIE TAX collection DISTRICT26 FAYETTE TAX collection DISTRICT27 FOREST TAX collection DISTRICT28 FRANKLIN TAX collection DISTRICT29 FULTON TAX collection DISTRICT30 GREENE TAX collection DISTRICT31 HUNTINGDON TAX collection DISTRICTTCD CodeTax collection District32 INDIANA TAX collection DISTRICT33 JEFFERSON TAX collection DISTRICT34 JUNIATA TAX collection DISTRICT35

5 LACKAWANNA TAX collection DISTRICT36 LANCASTER TAX collection DISTRICT37 LAWRENCE TAX collection DISTRICT38 LEBANON TAX collection DISTRICT39 LEHIGH TAX collection DISTRICT40 LUZERNE TAX collection DISTRICT41 LYCOMING TAX collection DISTRICT42 MCKEAN TAX collection DISTRICT43 MERCER TAX collection DISTRICT44 MIFFLIN TAX collection DISTRICT45 MONROE TAX collection DISTRICT46 MONTGOMERY TAX collection DISTRICT47 MONTOUR TAX collection DISTRICT48 NORTHAMPTON TAX collection DISTRICT49 NORTHUMBERLAND TAX collection DISTRICT50 PERRY TAX collection DISTRICT51 PHILADELPHIA TAX collection DISTRICT52 PIKE TAX collection DISTRICT53 POTTER TAX collection DISTRICT54 SCHUYLKILL TAX collection DISTRICT55 SNYDER TAX collection DISTRICT56 SOMERSET TAX collection DISTRICT57 SULLIVAN TAX collection DISTRICT58 SUSQUEHANNA TAX collection DISTRICT59 TIOGA TAX collection DISTRICT60 UNION TAX collection DISTRICT61 VENANGO TAX collection DISTRICT62 WARREN TAX collection DISTRICT63 WASHINGTON TAX collection DISTRICT64 WAYNE TAX collection DISTRICT65 WESTMORELAND TAX collection DISTRICT66 WYOMING TAX collection DISTRICT67 YORK TAX collection DISTRICTTCD CodeTax collection DistrictCLGS-32-4 (8-11)Tax collection Districts