Southwest Regional Tax Bureau

IT-5
Employee's Request to Withhold Local Earned Income Tax

Click here to download and print IT-5 Forms in PDF format

Or, you can fill in and print the forms below. (Please note that any information that you type into this form will NOT BE SAVED!)

Please Complete in Duplicate: One Copy for the Tax Bureau and One Copy for Employer Files

Taxpayer's Name: Taxpayer's S.S.#: --
Home Address: Telephone Number: ()-
(Must include Street with PO Box)
City/State/Zip:
Taxing Districts
School District: Code No: Percent %:
Municipality:
Township/ Borough/ City		 Code No: Percent %:
Employer Fed. ID#: Employer Phone# ()-
Employer Name:
Employer Address:
City/State/Zip:

Being subject to Earned Wage of Income Tax in the taxing jurisdiction names on this form, I hereby request and authorize you to deduct each pay, at the payment of compensation to me the Earned Wage or Income Tax Due and payable by me thereon and to remit said amounts to the Earned Income Tax Officer. Further I understand that even though this Tax is being withheld, that I must still file a Final Earned Income Tax Return for the Tax Year.
Signature: Date:
Mail To: Southwest Regional Tax Bureau, One Centennial Way, Scottdale, PA 15683




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This page last modified on 4/7/08

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Last modified: 4/7/08.