Form Dscb:15-134a - Docketing Statement - Departments Of State And Revenue

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Docketing Statement DSCB:15-134A (Rev 2012)
BUREAU USE ONLY:
Departments of State and Revenue
Dept. of State Entity # _______________________
One (1) required
Dept. of Rev. Box # _________________________
Filing Period ____________Date 3 4 5 __________
SIC/NAICS _____________Report Code ________
Check proper box:
Pennsylvania Entities
Foreign Entities
State/Country
Date______
d
business stock
business non-stock
business
professional
____ benefit
nonprofit stock
nonprofit
nonprofit non-stock
limited liability company
statutory close
restricted professional
management
limited liability company
cooperative
business trust
insurance
____ benefit
Other
limited liability company
restricted professional
domestication
limited liability company
division
business trust
consolidation
1. Entity Name:
2. Individual name and mailing address responsible for initial tax reports:
Name
Number and street
City
State
Zip
3. Description of business activity:
4. Specified effective date, if any:
5. EIN (Employer Identification Number), if any:
month/day/year
hour, if any
6. Fiscal Year End:
7. Fictitious Name (only if foreign corporation is transacting business in PA under a fictitious name):

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