Form Rev-181 Cm - Application For Tax Clearance Certificate - 2008 Page 2
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41810008201
Page 2
Were the assets or activities of the business acquired in whole or in part from a prior business entity?
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Yes
No ( If “Yes”, give predecessor’s name, address and acquisition date. )
Name
Acquisition Date
/
/
P.O. Box, Street and Number
City or Town
County
State
ZIP Code
Has the business held title to any real estate in the last five years from the date of this application?
Yes
No
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G If “Yes”, complete Schedule A (last page).
G If you currently hold title to real estate in PA, complete Schedule B (last page).
Will the assets or activities of the business be transferred to another?
If “Yes”, complete:
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Name of New Owner
A.
Corporation
Yes
No
F. Other
Yes
No
B.
Partnership
Yes
No
Explain:
Street Address of New Owner
C.
Proprietorship
Yes
No
D.
Liquidating Trust
Yes
No
City
State
ZIP Code
E.
Association
Yes
No
Purpose of Clearance Certificate (check appropriate block):
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A. Dissolution of Corporation or Association through Department of State.
B. Dissolution of Corporation or Association through Court of Common Pleas. Date Court was petitioned and county:
/
/
(date)
(county)
C. Withdrawal of Foreign Corporation through Department of State
D. Merger or consolidation of two or more Corporations or Associations where surviving Corporation or Association is not subject to the jurisdiction
of Pennsylvania. (See 15 Pa C.S. § 139.)
/
/
E. Bulk Sale Clearance Certificate under Section 1403 of the Fiscal Code. Sale date:
Copy of settlement statement:
Corporation Tax Purposes
Employer Withholding Tax Purposes
Sales, Use and Hotel Occupancy Tax Purposes
Unemployment Compensation Tax Purposes
STATEMENT OF AUTHORIZATION
I authorize the PA Department of Revenue to disclose, verbally or in written form, all tax filings, payments or delinquencies
requested by the buyer or his representatives for the bulk sale transfer provision.
Authorized by
Title
Date
F. Foreign Corporation Clearance Certificate under the provisions of the Act of 1947, P.L. 493, Contract Number and Political Subdivision:
Location of business records, available for audit of Pennsylvania operations.
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P.O. Box, Street and Number
City
State
ZIP Code
Telephone Number
(
)
List any matters pending with the PA Department of Revenue (e.g. petitions, appeals):
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Did the business ever, within the Commonwealth of PA:
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(a)
Engage in the sale of soft drinks or soft drink syrup ......................................................................
Yes
No Period
/
/
to
/
/
(b)
Own or lease and operate diesel-powered motor vehicles on PA highways? ..............................
Yes
No Period
/
/
to
/
/
(c)
Engage in the sale of diesel fuel to motor vehicles using PA highways? ......................................
Yes
No Period
/
/
to
/
/
(d)
Engage in the sale or lease of tangible personal property since Sept. 1, 1953? ..........................
Yes
No Period
/
/
to
/
/
(e)
File PA Unemployment Compensation Reports? ..............................................................................
Yes
No Period
/
/
to
/
/
If “Yes”, give Account Number
(See question 8k.)
Have you terminated your business activities in Pennsylvania?
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Yes
No
G If “Yes”, give distribution of assets date:
G If “No”, explain:
G If a Foreign Corporation, have you terminated business in the state of your incorporation?
Yes
No
1810008201
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