Form Rev-181 Cm - Application For Tax Clearance Certificate - 2008
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41810008101
REV-181 CM (8-08)
DEPARTMENT USE ONLY
APPLICATION FOR TAX
BOX NUMBER
CLEARANCE CERTIFICATE
Bureau of Compliance
PO BOX 280947
TAX TYPE
K-
NO FILING FEE
Harrisburg PA 17128-0947
Please Type or Print
Name of Business
Federal Employer Identification Number
1
2
Location of Business (Current Mailing Address)
P.O. Box, Street and Number or R.D. Number and Box Number
Telephone Number
(
)
City or Town
County
State
ZIP Code
Name, Address and Phone Number of Attorney or Representative to whom Clearance Certificate should be sent (if different from #2)
3
Name
Telephone Number
(
)
P.O. Box, Street and Number or R.D. Number and Box Number
City or Town
County
State
ZIP Code
Name ( s), Home Address(es) and Social Security Number(s) of Sole Proprietor, General Partners, Business Trustee, President and Treasurer of the
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Corporation or Chief Executive Officer or Majority Owner of Entity. (Attach listing if necessary.)
Name
Social Security Number
Telephone Number
(
)
P.O. Box, Street and Number or R.D. Number and Box Number
City
State
ZIP Code
Name
Social Security Number
Telephone Number
(
)
P.O. Box, Street and Number or R.D. Number and Box Number
City
State
ZIP Code
Type of Business
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DOMESTIC CORPORATION (Incorporated in PA)
FOREIGN CORPORATION (not incorporated in PA)
NONPROFIT CORPORATION
(Please submit copy of 501(c)
PARTNERSHIP
PROPRIETORSHIP
exemption letter)
ASSOCIATION
BUSINESS TRUST
LIQUIDATING TRUST
LIMITED LIABILITY PARTNERSHIP
OTHER (Specify)
LIMITED LIABILITY COMPANY
If Domestic Corporation, give incorporation date.
If Foreign Corporation, give state where incorporated and date of Certificate of Authority in PA.
/
/
/
/
Registered Pennsylvania Address, P.O. Box, Street and Number
City or Town
County
State
ZIP Code
Date business started in Pennsylvania
Date terminated
/
/
/
/
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Describe the business activity in Pennsylvania, including services performed and rendered, and give principal commodity sold at wholesale or retail. If
sales or construction are involved, please explain. If manufacturer’s representatives or independent contractors perform activities, render services or
execute sales on behalf of the entity rather than entity’s employees, please specify what activities were performed, what services were rendered and
what type of sales were executed.
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Did the entity have employees for which PA Personal Income Tax was required to be withheld from wages?
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Did taxpayer ever hold any of the following Licenses, Permits or Accounts with the Commonwealth of PA?
to
(a)
Corporation Tax
Yes
No
Period
/
/
/
/
Box
No.
to
(b)
Malt Beverage or Liquor License
Yes
No
Period
/
/
/
/
License No.
to
(c)
Liquid Fuels
Yes
No
Period
/
/
/
/
Permit
No.
to
(d)
Cigarette Tax
Yes
No
Period
/
/
/
/
License No.
to
(e)
Sales, Use and Hotel Occ. Tax
Yes
No
Period
/
/
/
/
License No.
to
(f)
Motor Carrier
Yes
No
Period
/
/
/
/
License No.
to
(g)
Fuel Dealer-User
Yes
No
Period
/
/
/
/
License No.
to
(h)
Lottery
Yes
No
Period
/
/
/
/
Agent
No.
to
(i)
Small Games of Chance Mfg. / Distr.
Yes
No
Period
/
/
/
/
License No.
to
(j)
Public Transportation Assistance
Yes
No
Period
/
/
/
/
License No.
to
(k)
PA Unemployment Compensation
Yes
No
Period
/
/
/
/
Account No.
/
/
to
/
/
(l)
PA Oil Company Franchise Tax
Yes
No
Period
Account No.
1810008101
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