Earned Income Tax Employer Registration Form

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Upper Dublin Township
801 Loch Alsh Avenue
Ft. Washington, PA 19034-1697
Phone: (215) 643 - 1600
Fax: (215) 542 - 0797
Earned Income Tax Employer Registration Form
Please provide the following information so that we may update our files.
Name of Business/Company:
Mailing Address:
Property Location:
Address forms should be sent:
(if different from above)
Effective Date:
Federal Identification Number:
Number of Employees:
Please provide the following information for the contact person for Earned Income Tax processing for your
business:
Name:
Title:
Telephone Number:
FOR OFFICE USE ONLY:
Account #:
(PLEASE COMPLETE REVERSE SIDE)

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