Form 83-E669 - Change Form
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1
2CITY OF PHILADELPHIA
USE THIS FORM TO REPORT:
- Name and/or mailing address change
- Death of a taxpayer
DEPARTMENT OF REVENUE
- Close of business
- Add or cancel a City or School Tax liability
CHANGE FORM
- Incorrect Social Security or Federal ID Number - Need for a new coupon book
MAIL THE COMPLETED CHANGE FORM TO:
DEPARTMENT OF REVENUE CONTACT INFORMATION
CITY OF PHILADELPHIA
PHONE: 215-686-6600
DEPARTMENT OF REVENUE
E-MAIL: revenue@phila.gov
P.O. BOX 1410
INTERNET: phila.gov/revenue
PHILADELPHIA, PA 19105-1410
A single Change Form can be used for all tax types for which
OR FAX TO: 215-686-6635
you are liable. Clearly print or type all applicable items.
(If submitting by fax, do not mail this form.)
CURRENT REGISTRATION INFORMATION MUST BE COMPLETED FOR ALL CHANGE REQUESTS.
Currently Registered Taxpayer Name and Address
City Account Number
Employer Identification Number
-
Social Security Number
-
-
Spouse's Social Security Number
-
-
PART 1. BUSINESS AND WAGE TAXES
For a change of entity, use this form to cancel your account. You must apply for a new Philadelphia Tax Account Number and
Business Privilege License. See the contact information above to obtain the application.
TYPE OF ORGANIZATION (CHECK ONE)
E)
PARTNERSHIP
Check here if any member is a corporation.
SOLE PROPRIETOR
A)
CORPORATION
GENERAL PARTNERSHIP
LIMITED PARTNERSHIP
B)
LIMITED LIABILITY PARTNERSHIP
ESTATE/TRUST
C)
LIMITED LIABILITY COMPANY (LLC)
F)
D)
JOINT VENTURE
Check here if any member is a corporation.
INDICATE FILING BASIS WITH THE INTERNAL REVENUE SERVICE
SOLE PROPRIETORSHIP
CORPORATION
PARTNERSHIP
Business Name and Address
Employer Identification Number
-
Social Security Number
-
-
Telephone #
Fax #
Contact Person
E-mail Address
To request a new coupon book, add a tax, or if your business has closed, complete the appropriate information below.
ADD A NEW TAX TYPE
BUSINESS CLOSED OR NO LONGER HAVE TAXABLE WAGES
If your business never
materialized, check here:
-
-
-
-
Enter start date
Enter the last day of business
ADD
CANCEL
COUPONS
ADD
CANCEL
COUPONS
OUTDOOR ADVERTISING TAX
AMUSEMENT TAX
BUSINESS PRIVILEGE TAX
PARKING TAX
HOTEL TAX
VALET PARKING TAX
LIQUOR TAX
VEHICLE RENTAL TAX
NET PROFITS TAX
WAGE TAX
83-E669 Rev. 11/14/2007 Final
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