Application For Job Creation Tax Credit - Pennsylvania Department Of Revenue Page 3
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4City of Philadelphia
Department of Revenue
Certification:
To be signed by an authorized representative of the applicant.
I hereby certify that all information contained in this application and attachments are true and correct to the best of my
knowledge.
Signature of Representative:
_________________________________________________________________
Print Name of Representative:
________________________________________________________________
Title of Representative:
_________________________________________________________________
Applicant’s Name:
_________________________________________________________________
Representative’s Address:
_________________________________________________________________
Mail Completed Application To:
Revenue Commissioner
City of Philadelphia
Municipal Services Building
Room 630
1401 John F. Kennedy Boulevard
Philadelphia, PA 19102
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