DATE:

ORGANIZATION CODE: 1142043060

SOCIAL SECURITY NUMBER: __________________

TO:	Justice Payroll Services Center

FROM:	Antitrust Division

SUBJECT:	WITHHOLDING OF CITY EMPLOYMENT TAX ON NONRESIDENTS

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[__]	I hereby certify that I am a nonresident of the City of Philadelphia and a

Nonresident of the State of Pennsylvania.

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[__]	I do consent to withholding.

Amount Allocated........................$ ___________.

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[__]	I do not consent to withholding.

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(Signature)

RESIDENCE ADDRESS: ___________________________

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___________________________ ZIP CODE: ___________