INDIVIDUAL Tax Return. DO NOT combine spousal incomes.

____________________________________

e-file at www.keystonecollects.com

Check here if PART-YEAR RESIDENTComplete ITR-1 Schedule on reverse sideof this form and enclose copies of other municipal returns.

DO NOT STAPLE ANY ITEMS TO THIS RETURN

DUE DATE: 04/17/2012

546 Wendel RoadIrwin, PA 15642(724) 978-0300

___________________________________USE BLUE OR BLACK INK

* RETURN MUST BE FILED ON THIS FORM. No substitutions accepted.

RESIDENT OF MUNICIPALITY: _______________________________________

2011 Earned Income Tax ReturnKeystone Collections Group

Daytime Phone

Note all corrections/additions to SSN, name or addressand check box here.

1. Gross State Earnings as Reported on W­2/1099 Enclose copies with this form ......

2. Unreimbursed Employee Business Expenses (Enclose PA Schedule UE) .........

3. Taxable W­2/1099 Earnings (Line 1 minus Line 2) .................................................

4. Net Profit from Business, Profession or Farm (Submit PA Schedule C, F, RK­1 or 20­S) .................................................................................... Non Taxable S­Corp Earnings (check box)5. Net Loss from Business, Profession or Farm (Submit PA Schedule C, F, RK­1 or 20­S) .................................................................................... Non Deductible S­Corp Losses (check box)

6. Subtotal (Line 4 minus Line 5) IF LESS THAN ZERO, ENTER ZERO ....................

7. Total Earned Income and Net Profits (Line 3 plus Line 6) .....................................

8. Resident Tax (Line 7 multiplied by tax rate of ) ................................ (Tax Rate)

9. Credit for Earned Income Tax Withheld (Per W­2. See Instructions for Line 9) .....

10. Estimated Payments or Credit (Direct payment made by you and/or credit from prior year) .....................................................................................

11. Miscellaneous Credits Philadelphia Credit (check box) (See Instructions and Worksheet) Out Of State Credit (check box) .........

12. Total (Line 9 plus Line 10 plus Line 11) ....................................................................

13. REFUND/CREDIT (Line 12 minus Line 8) IF $1.00 OR MORE, enter amount & check box below. INCLUDE PA­40 INFO ­ See Instructions ...................................

Apply to spouse Apply to next year Refund

14. TAX DUE (Line 8 minus Line 12) OMIT IF LESS THAN $1.00 .................................

15. Penalty (See Instructions for Line 15) .......................................................................

16. Interest (See Instructions for Line 16) .......................................................................

17. TOTAL AMOUNT DUE (Line 14 plus Line 15 plus Line 16) .....................................

Under penalties of perjury, I (we) declare that I (we) have examined this information, including all accompanying schedules and statements and to the best of my (our) belief, they are true, correct and complete.

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ENTER ACCOUNT TOTALS ON LINES 17 AND 18

546 Wendel RoadIrwin, PA 15642(724) 978-0300

$

DUE DATE: 04/17/2012

Mail this return to the above address.THIS VOUCHER MUST BE INCLUDED WITH YOUR RETURN.

2011 EARNED INCOME TAX

13210111005041612000000000000000000005

Employer _______________________________

Local Income $ _______________ / 12 months X _____________ (months at this residence) = ________________

Withholding $ _______________ / 12 months X _____________ (months at this residence) = ________________

Local Income $ _______________ / 12 months X _____________ (months at this residence) = ________________

Withholding $ _______________ / 12 months X _____________ (months at this residence) = ________________

Current Residence Total Income ____________________ Total Local Tax Withheld ____________________

Previous Residence _____________________________________________(street address) # months at this

_____________________________________________ (Municipality, State, ZIP) residence

Employer _______________________________

Employer _______________________________

Employer _______________________________

_________________________________________________________________________________________________________________________________

Current Residence ______________________________________________ (street address) # months at this

______________________________________________ (Municipality, State, ZIP) residence

__ __

Local Income $ _______________ / 12 months X _____________ (months at this residence) = ________________

Withholding $ _______________ / 12 months X _____________ (months at this residence) = ________________

Local Income $ _______________ / 12 months X _____________ (months at this residence) = ________________

Withholding $ _______________ / 12 months X _____________ (months at this residence) = ________________

Previous Residence Total Income ____________________ Total Local Tax Withheld ____________________

Non­Reciprocal State/Philadelphia Credit Schedule ITR-2 Schedule

Use this schedule if you moved into a new taxing jurisdiction during the tax year.

Philadelphia Other State

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

*If you paid both out­of­state and Philadelphia wage tax, then enter on Line 11 of the local return the lower of (Line 4 plus Line 7) or (Line 2 (b) ). Remember, yourcredit cannot exceed your local tax liability.

Note: Do not use this non­reciprocal schedule ITR­2 for state earned income tax paid to the reciprocating states of Maryland, New Jersey, Ohio, Virginia, West Virginia and Indiana. To recover tax paid to a reciprocating state, you must apply for a refund from the state where you paid the tax.

Ver. 12­22­2011

Part­Year Resident Schedule ITR-1 Schedule

_________________________________________________________________________________________________________________________________

__ __

For income taxed in another state or taxed in the City of Philadelphia. Income: Earnings and Net Profits (as defined in Line 1 and Line 4 of the instructions) taxed in another state . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1(a) XXXXXXXX ____________

Total Earned Income and Net Profits Reported on Line 7 of Local Return . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1(b) ____________ XXXXXXXX

Maximum Credit Allowed: Line 1(a) x local rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2(a) XXXXXXXX ____________

Line 1(b) x local rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2(b) ____________ XXXXXXXX

Actual Tax Paid: Actual tax paid to other state . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3(a) XXXXXXXX ____________

Actual tax paid to Philadelphia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3(b) ____________ XXXXXXXX

Philadelphia Credit—Lesser of line 2(b) or Line 3(b)—enter on line 11 of local return . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 ____________ XXXXXXXX

Additional limitation for out of state credit: Line 1(a) x PA Income Tax Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 XXXXXXXX ____________

Line 3(a) minus Line 5 (Remaining credit after application to Pennsylvania State Tax) . . . 6 XXXXXXXX ____________

Out of state credit—Lesser of line 2(a) or Line 6—enter on line 11 of local return . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 XXXXXXXX ____________