Employer'S Registration For Withholding Earned Income Tax Form printable pdf download

Employer'S Registration For Withholding Earned Income Tax Form

LANCASTER COUNTY TAX COLLECTION BUREAU

1845 WILLIAM PENN WAY, SUITE 1

LANCASTER. PA 17601-6713

Telephone: (717) 569-4521

Fax: (717) 569-1623

EMPLOYER'S REGISTRATION FOR WITHHOLDING EARNED INCOME TAX

BUREAU ACCT #

___ __________________________________

(For Bureau Use Only)

FEDERAL EIN:

____________________________________

EMPLOYER'S NAME:

___________________________________________________________________

(Use Federal I.D. Name)

TRADE/BUSINESS NAME: ___________________________________________________________________

MAILING ADDRESS:

___________________________________________________________________

CITY & STATE:

___________________________________________ZIP:____________________

IMPORTANT –Please indicate if your business is located in Lancaster or Middletown and list all the locations

in each jurisdiction. (Use reverse side if necessary)

Lancaster Employer

Middletown Employer

PHYSICAL LOCATION(S): __________________________________________________________________

__________________________________________________________________

CITY & STATE:

__________________________________________ZIP:_____________________

CONTACT PERSON:

___________________________________________________

TELEPHONE NO:

(_________)_______________________________

FAX NO:

(_________)_______________________________

E-MAIL ADDRESS:

__________________________________________________________________

PAYROLL SERVICE (If Applicable)*: ____________________________

For Online Filing Purposes Only: If this account should be added to an existing payroll provider account, provide the name of the payroll

provider and payroll provider Federal ID Number.

DATE OF FIRST PAYROLL:

____________________________

TYPE OF ORGANIZATION:

Corporation

Sole Proprietorship

Partnership

Association

Other

I hereby certify the above information is true and complete to the best of my knowledge and belief and are made in good faith.

Signature:___________________________________Title:_______________________Date:_________________

Employer'S Registration For Withholding Earned Income Tax Form

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