Pa 78 Form – Fill Out and Use This PDF

The PA 78 form, known as the Request for Employment/Earnings Information, is a document used by employers to provide earnings and employment information upon request, in compliance with Pennsylvania law. This form is essential for individuals applying for, receiving, or having received public assistance, or those who are legally responsible relatives of the employee needing this information. It facilitates the reporting of salary, wages, and compensation amounts and dates, along with medical insurance coverage details, to designated authorities within a 30-day period, under the penalties established by law.

To ensure compliance and assist those in need of this vital information, it is crucial to fill out the PA 78 form accurately and return it promptly. Click the button below to begin filling out the form.

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Pa 78 Form PDF Details

Fulfilling the requirements of the Pa 78 form is a vital step in ensuring compliance with state mandates regarding the disclosure of employment and earnings information. The essence of this document centers around its primary role in assisting employees applying for, receiving, or who have received public assistance. Employers are compelled under the weight of legal obligation, enforceable by a fine of up to $1,000, to furnish detailed information concerning an employee's salary, wages, and other forms of compensation within a 30-day window. This process not only serves to verify the financial status of individuals seeking public aid but also plays a crucial role in maintaining the integrity and efficiency of public assistance programs. By requiring the disclosure of critical employment information, including but not limited to the employee's social security number, last known address, and specifics regarding earned income tax credits, the Pa 78 form facilitates a more streamlined and accurate assessment of eligibility for assistance. Furthermore, it touches on aspects of employer-provided medical insurance, capturing details such as the insurance company, coverage dates, and policy specifics. Ensuring the provision of earnings data by specific pay dates rather than in aggregate quarterly or yearly amounts enhances the form's precision, making it an indispensable tool in the administration of state-supported aid programs.

Question	Answer
Form Name	Pa 78 Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	form pa 78, pa 78 form online, pa 78, erie cao form pa78a

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REQUEST FOR EMPLOYMENT/EARNINGS INFORMATION

CO	RECORD	DIST	CASE LOAD

	CAO DISC		DATE OF NOTICE

	WORKER NAME

TELEPHONE NUMBER			FAX NUMBER

PLEASE FAX OR RETURN TO ADDRESS SHOWN ON BACK OF THIS FORM

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 ALEGALLY RESPONSIBLE RELATIVE OF THE EMPLOYEE.

					*AFINE NOT TO EXCEED $1,000

				SUBJECT OF INQUIRY
EMPLOYEE’S NAME					SOCIALSECURITYNUMBER

COMMENT:					LASTKNOWN ADDRESS:

				EMPLOYER INFORMATION

EMPLOYEE TELEPHONE NUMBER					EARNED INCOME TAX CREDIT(EIC) RECEIVED
(	)				YES	NO
					YES	NO

IS INDIVIDUALCURRENTLYEMPLOYED		YES		NO	IF NO, REASON FOR TERMINATION

			EMPLOYER MEDICALINFORMATION
MEDICALINSURANCE COMPANY				MEDICALINSURANCE COMPANYADDRESS

DATES OF COVERAGE		TYPE OF COVERAGE			POLICY/CONTRACTNUMBER		GROUPNAME/NUMBER
FROM	TO


	Please provide earnings information by DATE of PAY
	as indicated ON REVERSE SIDE
							PA78A-X 7/09

PROVIDE EARNINGS INFORMATION BY PAY PERIOD FROM ___________________ TO PRESENT. PLEASE DO NOT

USE QUARTERLY OR YEARLY AMOUNTS. A COMPUTER PRINTOUT OF THE EARNINGS DATA MAY BE SUBSTITUTED IF IT CONTAINS ALLOF THE REQUESTED INFORMATION. ACTUALDATES OF PAYMUST BE INCLUDED, NOT MERELY “PAYPERIOD ENDING” OR “WEEK ENDING” INFORMATION. PLEASE PRINT OR TYPEAND SIGN YOUR NAME BELOW.

DATE OF PAY	GROSSAMOUNT	ADVANCED EIC

DATE OF PAY	GROSSAMOUNT	ADVANCED EIC

USE THIS SPACE FOR ADDITIONALCOMMENTS:

EMPLOYER’S REPRESENTATIVE

TITLE

SIGNATURE

PHONE NUMBER

DATE

(PLEASE PRINT)

FIRST-CLASS MAILPERMITNO 9314 HARRISBURG PA

POSTAGE WILLBE PAID BYADDRESSEE

PA78A-X 7/09

How to Edit Pa 78 Form Online for Free

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It is actually easy to finish the form with our practical tutorial! Here's what you have to do:

1. Start completing your pa 78a form with a number of necessary blanks. Gather all of the necessary information and make certain not a single thing missed!

Guidelines on how to complete pa78a stage 1

2. Immediately after the first section is done, go to enter the suitable information in these: EMPLOYEES NAME, COMMENT, SUBJECT OF INQUIRY, SOCIAL SECURITY NUMBER, LAST KNOWN ADDRESS, COMPLETE THE INFORMATION REQUESTED, IF THE PERSON IS OR WAS EVER IN, EMPLOYER INFORMATION, EMPLOYEE TELEPHONE NUMBER, EARNED INCOME TAX CREDIT EIC, YES, IS INDIVIDUAL CURRENTLY EMPLOYED, YES, IF NO REASON FOR TERMINATION, and MEDICAL INSURANCE COMPANY.

Always be very attentive while completing COMMENT and SOCIAL SECURITY NUMBER, since this is the section where many people make a few mistakes.

3. This stage is straightforward - fill in every one of the form fields in PROVIDE EARNINGS INFORMATION BY, DATE OF PAY, GROSS AMOUNT, PRETAX, DEDUCTIONS, DATE OF PAY, GROSS AMOUNT, PRETAX, and DEDUCTIONS in order to complete this part.

pa78a writing process detailed (portion 3)

4. To go forward, this step will require filling out a few empty form fields. Examples include USE THIS SPACE FOR ADDITIONAL, EMPLOYERS REPRESENTATIVE, TITLE, SIGNATURE, PHONE NUMBER, DATE, and PLEASE PRINT, which are fundamental to going forward with this particular document.

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Pa 78 Form – Fill Out and Use This PDF

Pa 78 Form PDF Details

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