Form 83-T-5 - Application For Philadelphia Business Tax Account Number Business Privilege License Wage Tax Withholding Account
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1CITY OF PHILADELPHIA
DEPARTMENT USE ONLY
APPLICATION FOR
PHILADELPHIA BUSINESS TAX ACCOUNT NUMBER
PHILA DELPHIA BUSINES S TAX ACCOUNT NUMBER
BUSINESS PRIVILEGE LICENSE
-
WAGE TAX WITHHOLDING ACCOUNT
READ INSTRUCTIONS ON REVERSE BEFORE COMPLETING THIS FORM
PHILADELPHIA BUSINES S PRIV ILE GE LICENSE NUMBER
CLEARLY PRINT OR TYPE ALL INFORMATION
1A. IF THIS ACCOUNT IS FOR WAG E TAX WITHHOLDING ONLY, CHECK HERE
FEDERAL EMPLOYER IDENTIFICATIO N NUMBER
1B. IF THIS ACCOUNT IS FOR NET PROFITS TAX ONLY , CHECK HERE
-
2. DATE PHILADELP HIA BUSINESS BEGAN
3. DO YOU NEED PRIOR YEAR(S) TAX FO RMS?
-
-
YES
NO
SOCIAL SE CURITY NUMBER
5. TAXAB LE MONTHLY PAY ROLL
4. DATE WAG ES FI RST PAI D
-
-
-
-
6. PRIMARY TYPE OF BUSINESS
YOU MUST ENTER YOUR FEDERAL EMPLOYER
IDENTIFICATION AND/OR SOCIAL SECURITY NUMBER
RETAIL
CONSTRUCTION
WHOLESA LE
MANUFACTURING
SERVICES
OTHER
6A. DESCRIBE EXACT TY PE O F BUSINES S
7. PA. STATE SALES TA X NUMBER
-
8. ENTITY NAME
8A. TRADE NAME (IF A PPLICABLE)
9. MAILING ADDRESS
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
10. BUSI NESS A DDRESS (NUMBER AND STREET. DO NOT USE P .O. BOX NUMBERS.)
OWN RENT
11. BRANCH OFFICE A DDRESS (IF ANY) IF MORE THAN ONE LOCATI ON, ATTACH A SEPARATE SHEET.
CITY
STATE
ZIP CODE
OWN
RENT
12. BUSI NESS TE LEP HONE NUMBER
13. HOME TELEPHONE NUMBER
14. FAX NUMBER
15. E-MAIL ADDRESS
16. TYPE OF O RGANIZATIO N (CHECK ONE)
LIMITED LIABILITY COMP ANY (LLC)
PARTNERSHIP
JOINT VENTURE
D)
E)
F)
A)
SOLE PROPRIETOR
FILING BAS IS WITH THE I NTERNAL REVENUE SERVICE:
GENERAL PARTNERSHIP
(darken one circle)
Check here if any member
LIMITED P ARTNERSHIP
CORPORATION
CORPORATION
B)
is a corporation.
SOLE PROP RIETOR
LIMITED LIABILI TY PA RTNERSHIP
Check here if any member
C)
ESTATE/TRUST
PARTNERSHIP
is a corporation.
NON-PROFIT UNDER INTERNAL REVENUE CODE §501(C) (3).
WAGE TAX O NLY
GOVERNME NT
ASSO CIATION
G)
H)
I)
ATTACH A COPY OF THE IRS EXEMPTION LETTER.
17. INDIVI DUALS, PARTNERS OR O FFICERS NAMES
18. HOME ADDRESS
19. SO CIAL SECURITY NUMBER OR FEDERAL EIN
20A. V OLUNTARY DISCLOSURE OF RACE AND GENDER INFORMATION
CITY OF PHILADELPHIA USE ONLY
REVENUE CODE 3702
RACE/NATIONAL ORI GIN:
ASIAN, PACIFIC ISLANDER
BLACK
HISPANIC
WHITE
OTHER
MAIL COMPLETED APPLICATION TO:
(specify)__________ ________ ______________________ ________ ____
CITY OF PHILADELPHIA
DEPARTMENT OF REVENUE
SEX:
MALE
FEMALE
P.O. BOX 1600
20B . PRIMARY LANGUAG E OF BUSINESS OWNER
PHILADELPHIA, PA 19105-1600
ENGLISH
SPANISH
KOREAN
OR FAX TO: 215-686-6635
(If submitting by fax, do not mail.)
RUSSIAN
OTHER (specify)________________ ________ ___
I understand that if I knowingly make any false sta tement(s) herein, I am subject to penalties a s prescribed by law.
____________________________
______________________
_____________
_________
SIGNATURE
PRINT NAME
PHONE NUMB ER
DATE
83-T-5 Rev. 5-25-2005
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