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Discontinuation Of Business Activity Form - The City Of Pittsburgh Department Of Finance Page 2

BUSINESS ACTIVITY INFORMATION – CONTINUED

Date business moved:

___________________________________________

(5)

If the business is still in operation, do you employ Pittsburgh

residents? (If completely discontinued, skip to part B).

YES

Final quarter in which Pittsburgh resident tax was withheld - _________________________

(6)

Are you a City resident?

YES

(7)

Will any business activity be conducted in Pittsburgh?

YES

If YES, please describe: _______________________________________________________

__________________________________________________________________________

B. AFFIRMATION:

I, _________________________________________, _______________________________________

(Owner name / Officer (if corporation) please print)

(Business name)

do hereby affirm that this document has been examined by me and to the best of my knowledge

and belief, is true, correct and complete.

SIGNATURE___________________________, ________________, __________________________

(Signature)

(Date)

(Telephone No.)

Resident Address: _____________________________, ____________________, ________________,__________

(Street)

(City)

(State)

(ZIP)

Mail completed form to:

BEN COGAN, AUDITOR

CITY OF PITTSBURGH

DEPARTMENT OF FINANCE

414 GRANT ST RM 206

PITTSBURGH PA 15219

For questions regarding this form, please dial 412-255-2554

Rev-1-14

Discontinuation Of Business Activity Form - The City Of Pittsburgh Department Of Finance Page 2