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

Form Dscb:15-134a - Docketing Statement Departments Of State And Revenue - 1995 Page 2

DSCB:15-134A (Rev 95)-2

7. Names, residences and social security numbers of the chief executive officer, secretary and treasurer or individual responsible for

maintaining financial records:

Name

Address

Title

Social Security #

______________

If professional association, include officer's professional license numbers with the respective Pennsylvania Professional Board.

8. Location of principal place of business:

____

_________

Number and Street/RD number and Box

City

State

Zip

9. Mailing address if different than #8 (Location where correspondence, tax report form, etc. are to be sent):

_____

__________

Number and Street/RD number and Box

City

State

Zip

10. Act of General Assembly or authority under which you are organized or incorporated (Full citation of statute or other

auth ority;

attach a separate sheet if more space is required):

___

______

_______

11. Date and state of incorporation or organization (foreign association only):

_______

12. Date business started in Pennsylvania (foreign association only):

_______

13. Is the association authorized to issue capital stock?

YES

14. Association's fiscal year ends:

____

_______

This statement shall be deemed to have been executed by the individual who executed the accompanying submittal. See 18 Pa.C.S.

§4904 (relating to unsworn falsification to authorities).

Instructions for Completion of Form:

A. A separate completed set of copies of this form shall be submitted for each entity or registration resulting from the

transaction.

B. The Bureau of Corporation Taxes in the Pennsylvania Department of Revenue should be notified of any address

changes. Notification should be sent to the Processing Division, Bureau of Corporation Taxes, Pa. Department of Revenue,

Dept. 280705, Harrisburg, PA 17128-0705.

C. All Pennsylvania corporate tax reports, except those for motor vehicle for hire, must be filed with the Commonwealth on

the same fiscal basis as filed with the U.S. government. Motor vehicle for hire, i.e., gross receipts tax reports, must be filed

on a calendar year basis only.

D. The disclosure of the social security numbers of the corporate officers in Paragraph 7 is voluntary. The numbers are

used to assure the proper identification of corporation officers by the Department of Revenue in accordance with the Fiscal

Code.

Form Dscb:15-134a - Docketing Statement Departments Of State And Revenue - 1995 Page 2

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