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Get PA PA 78A-X 2009

IMPORTANT 62 PS 487 (B) REQUIRES, UNDER PENALTY OF LAW,* THAT YOU COMPLETE THIS FORM UPON REQUEST AND RETURN IT WITHIN 30 DAYS TO THE ADDRESS ON THE BACK OF THIS FORM. EVERY EMPLOYER IS REQUIRED, WHEN REQUESTED IN WRITING FROM THE DEPARTMENT, TO DISCLOSE ANY MONEY IN SALARY, WAGES, COMPENSATION, AND THE AMOUNTS AND DATES OF SUCH SALARY. THE DEPARTMENT CERTIFIES THAT THE EMPLOYEE BELOW IS APPLYING FOR, RECEIVING OR DID RECEIVE PUBLIC ASSISTANCE, OR IS A LEGALLY RESPONSIBLE RELATIVE OF THE EMPLOYE.

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