Earned Income Tax Registration Form Page 2
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1
2TAXPAYER III
NAME
SOC SEC NUM
Last
First
MI
ADDRESS
Number
Street
Post Office
DATE OF RESIDENCE
Own
Rent
If renting, name of owner:
EMPLOYMENT STATUS:
Part-time
Employed: Full-time
Not Employed
Self-employed
TAX STATUS IF EMPLOYED:
No Local Tax Withheld
Phila. Wage Tax Withheld
Local Tax Withheld for:
(Locality)
EXEMPT FROM TAX FOR FOLLOWING REASON:
Active Military
Permanently retired as of
Temporarily Unemployed
Permanently disabled as of
Other
Full-time Homemaker
SIGNATURE
DATE
************************************************************************************************************************
TAXPAYER IV
NAME
SOC SEC NUM
Last
First
MI
ADDRESS
Number
Street
Post Office
DATE OF RESIDENCE
Own
Rent
If renting, name of owner:
EMPLOYMENT STATUS:
Part-time
Employed: Full-time
Not Employed
Self-employed
TAX STATUS IF EMPLOYED:
No Local Tax Withheld
Phila. Wage Tax Withheld
Local Tax Withheld for:
(Locality)
EXEMPT FROM TAX FOR FOLLOWING REASON:
Active Military
Permanently retired as of
Temporarily Unemployed
Permanently disabled as of
Other
Full-time Homemaker
SIGNATURE
DATE
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