Local Tax

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					                               Duquesne University - Payroll Department
                   Authorization for Local Tax Withholding -- Full Time Employees Only
Please check         the appropriate box:

New Employee
Change in Locality

Employee information (Please Print):

  Last 4 Digits of your Social Security Number
                  Current Address

                                            Old                                                    New

Locality                                                           Locality
School District                                                    School District
County                                                             County
Tax %                                                              Tax %
Dates of Occupancy                                                 Dates of Occupancy

I hereby authorize Duquesne University to withhold local taxes for the above named locality. I understand that
Duquesne University will submit quarterly payments on my behalf to my local tax authority at the percentage listed. I
will also complete a new Authorization for Local Tax Withholding form and return it to Payroll within 5 days should any
modifications occur from the information provided such as change of address or and adjustment to my tax percentage.

    Employee's Signature:

I hereby authorize Duquesne University to retroactively deduct taxes for the current quarter.

    Employee's Signature:

           Once completed, please print document and return to the Payroll Department via interoffice mail .
                Please do NOT send this document via email because it contains your security information.
            If you are not on campus, please send the document via postal mail to the following address :

                                                        Payroll Department
                                                  Room 202 Administration Building
                                                          600 Forbes Ave
                                                       Pittsburgh, PA 15282
                                                          (412) 396-6579

                                     ***************(Official Use Only)***************

Locality Code:

Documented on:

Effective Pay Date: