Change Form - Philadelphia Department Of Revenue printable pdf download

Change Form - Philadelphia Department Of Revenue

Philadelphia Department of Revenue

CHANGE FORM

Use this form to report: change of name and / or mailing address

- cancellation of business activity

- change in business entity (e.g., from an individual to a corporation)

Current information: (complete the applicable items – please print)

Name: _______________________________________________________

Address: _____________________________________________________

_____________________________________________________________

Entity Type: Individual __ Partnership __ Corporation __ Other_________

Federal EIN or Social Security #: __________________________________

Philadelphia Tax Account #: _____________________

New information: (complete the applicable items – please print)

Name: _______________________________________________________

Address: _____________________________________________________

_____________________________________________________________

Entity Type: Individual __ Partnership __ Corporation __ Other________

For a change in entity, you need to apply for a new Philadelphia tax account number and

obtain a new business privilege license. The necessary forms can be downloaded from our

web site: or call 215-686-6600.

New EIN #: ____________________ Effective Date: ________________

Phone #: __________________ Contact Person: ____________________

Fax #: _________________ e-mail address: ________________________

Cancellation Information: Cancellation Date: _______________

Tax types to be cancelled: Business Privilege____ Net Profits_______

Wage___ Other (please specify): ________________________

If business was sold, indicate new owner name and address

: Name_________________________________________________

: Address________________________________________________

_______________________________________________________

Mail this form to: Philadelphia Department of Revenue

P.O. Box 1620

Philadelphia, PA 19105-1620

Fax to: 215-686-6635

Send e-mail to: revenue@phila.gov

Change Form - Philadelphia Department Of Revenue