Withholding Of City Employment Tax On Nonresidents

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	U.S. Department of Justice Antitrust Division

DATE:
ORGANIZATION CODE: 1142043060
SOCIAL SECURITY NUMBER: __________________

TO:	Justice Payroll Services Center
FROM:	Antitrust Division
SUBJECT:	WITHHOLDING OF CITY EMPLOYMENT TAX ON NONRESIDENTS

_______	I hereby certify that I am a nonresident of the City of Philadelphia and a Nonresident of the State of Pennsylvania.
_______	I do consent to withholding. Amount Allocated........................$ ___________.
_______	I do not consent to withholding.

_______________________________
(Signature)

RESIDENCE ADDRESS:

______________________________________

ZIP CODE: ___________

Updated June 25, 2015