Form 83-E669 - Change Form Page 2

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PART 2. SCHOOL INCOME TAX
Corrected Social Security Number
Corrected Taxpayer's Name
-
-
Spouse's Corrected Social Security Number
Corrected Spouse's Name
-
-
New Address
Telephone #
Fax #
E-mail Address
Social Security Number
Taxpayer's Name
-
-
Cancellation Date
Reason
Moved out of Philadelphia
Spouse Filing Separately
for
-
-
Deceased
No taxable Income
Cancellation
Spouse's Social Security Number
Spouse's Name
-
-
Cancellation Date
Reason
Moved out of Philadelphia
Spouse Filing Separately
for
-
-
Deceased
No taxable Income
Cancellation
PART 3. BUSINESS USE and OCCUPANCY TAX
Business U&O Tax Account Number
Property Address
-
Property Account Number
Mailing Address (If different from Property Address)
Telephone #
Fax #
E-mail Address
Cancellation Date
Reason
Sold *
Residential
for
-
-
Vacant
Tax Exempt
Cancellation
Date of Purchase
Name of New Property Owner
-
-
* If the property has been sold, you must provide documentation. For example, a copy of the settlement sheet or deed.
PART 4. EMPLOYEE EARNINGS TAX
Corrected Social Security Number
Taxpayer's Name
-
-
New Address
Telephone #
Fax #
E-mail Address
If you are canceling this account, complete the appropriate information below.
Cancellation Date
Reason
Moved out of Philadelphia
Employer now withholding tax
for
-
-
Deceased
No longer employed
Cancellation

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