Keystone Opportunity Zone Application Form

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Keystone Opportunity Zone Application
Real Property Owner – This application must be sent to the local KOZ Coordinator to be filed with the County
Assessors Office for each property in the KOZ within 30 days of KOZ designation, or within 30 days any change of
st
ownership; and January 31
of each calendar year thereafter
Business – This application must be sent to the local KOZ Coordinator to be filed with the Department of
Community and Economic Development for approval for each business in the KOZ.
Resident – This application must be sent to the local KOZ Coordinator for each resident to be filed with the
Department of Community and Economic Development for approval.
Check all that apply: Real Property Owner______; Business______; Resident______
1. Name
(property owner, business or resident)
2. Trade Name (if any)
3. KOZ Address
Municipality ________________
_____________County_________________County Code#_
School District ______________________________________
_____School Dist Code#
Tax Parcel ID Number(s) ___________________________________________________________
4. Mailing Address
___
________________________________
City _______________ _________________
State __________ Zip ________
5. Tax ID Numbers:
EIN __ __ - __ __ __ __ __ __ __
Corporate Box __ __ __ __ __ __ __
Sales Tax __ __ - __ __ __ __ __ __
U.C. # ________________________
Any other tax ID Number (i.e., fuel tax) _________________
SS No. (sole proprietorship or resident) __ __ __ - __ __ - __ __ __ __
o
o
o
6. Type of Entity:
C Corp.
Sole Proprietorship
Non-Profit
o
o
o
S Corp.
Partnership
Other (please state)
7. Contact name ______________________________________ Phone number
All Sub-Chapter “S” corporations and partnerships are required to provide a listing of all shareholders or partners on attached sheet. Sub-
Chapter “S” corporation must have made proper “S” election in Pennsylvania. Partnership means a domestic or foreign general partnership, joint
venture, limited partnership, limited liability company, business trust or other unincorporated entity that for Federal Income Tax purposes is
classified as a partnership.
Requirement: In accordance with Sections 903 and 904 of the act of October 2, 1998 (P.L. 705, No. 92) known
as the Pennsylvania Keystone Opportunity Zone Act all "qualified businesses" and "persons" must be in full
compliance with all State and Local tax laws, and building and housing code provisions, in order to be
entitled to claim any exemptions, deductions, abatements or credits offered in the Act.
Any person who knowingly files an application which is false shall be subject to payment of taxes due, plus
interest, plus penalty and shall be subject to civil penalties and criminal prosecution as a misdemeanor of
the third degree.
I hereby certify that all the above information is true and correct:
Signature
Date
Print Name Title (if filing for business)
First Date in Zone

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