Form 5r As - Tax Account Information Change/correction Form

R E V-1705R AS (7-06)

TA X A CC OU N T I NF OR M AT I ON CH AN G E/ C OR R EC T IO N F OR M

PA D E PA RT M E N T O F R E V E N U E

If your EIN was changed by the IRS, you must complete a new registration form (PA-100). SALES/USE TAX, PTA, VRT AND CIGARETTE DEALER’S LICENSES ARE NON-TRANSFERABLE.

SECTION I.

EXISTING TAX A C C O U N T I D

E N T I T Y ID (EIN/SSN)

CORRECT ENTITY ID (EIN/SSN)

C U R R E N T FILING STAT U S

CHANGE FILING STATUS TO: (CHECK ONLY ONE –

MORE FREQUENT FILING STATUS ONLY )





EXISTING LEGAL NAME/TRADE NAME/ADDRESS

NEW LEGAL NAME/TRADE NAME/ADDRESS

S E C T I O N I I.

S A L E S :

M O N T H LY

Q U A RT E R LY





L E G A L

L E G A L

E M P L O Y E R:

S E M I - M O N T H LY

M O N T H LY

N A M E

N A M E

S E C T I O N I I I . ADD LOCAL SALES TA X

T R A D E

T R A D E

N A M E

N A M E

C O U N T Y:

DATE OF FIRST SALE IN COUNTY:

M O N T H

D AY

Y E A R

P R I M A RY

P R I M A RY



A L L E G H E N Y

/

/

A D D R E S S

A D D R E S S



P H I L A D E L P H I A

/

/

S E C T I O N I V. OTHER TAX CHANGES

L O C AT I O N

L O C AT I O N

TYPE OF TA X :

A C C O U N T ID NUMBER:

A D D R E S S

A D D R E S S



SALES/USE TA X



(NO PO BOX)

(NO PO BOX)

EMPLOYER TA X



M A I L I N G

M A I L I N G

P TA TA X



V RT

A D D R E S S

A D D R E S S



CIGARETTE

S E C T I O N V.

IN D I V I D U A L OWNER(S), PA R T N E R ( S ) O R C O R P O R AT E O F F I C E R (S) RESPONSIBLE FOR RETURN INFORMATION. Ownership change requires a new registration form (PA - 1 0 0 ) .

N A M E

S S N

NAME

S S N

M A I L TO :

PA D E PA RT M E N T OF REVENUE

D AT E

D AYTIME TELEPHONE

EXT.

S I G N AT U R E / T I T L E

E - M A I L A D D R E S S

PO BOX 280901

(

)

HARRISBURG, PA 1 7 1 2 8 - 0 9 0 1