Form Rev-976 - Election Not To Be Taxed As A Pennsylvania S Corporation

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FILL IN FORM USING ALL CAPS.DO NOT USE DASHES (-) OR SLASHES (/) IN ANY FIELD. ENTER DATES AS MMDDYYYY. USE WHOLE DOLLARS ONLY.
REV-976 (05-16) (FI)
ELECTION NOT TO BE TAXED AS
A PENNSYLVANIA S CORPORATION
BUREAU OF CORPORAtION tAxES
PA S UNIt
PO BOx 280701
HARRISBURG PA 17128-0701
START
Corporation is not subject to PA corporate
net income tax; election is for PA resident
shareholder purposes only.
Revenue Id
Federal Employer Identification Number (FEIN)
Election is to be first effective for:
tax year beginning:
MMddYYYY
Please fill in Corporate Name, Address, City, State and ZIP Code above.
Election is for this corporation and its qualified subchapter S
tax year ending:
MMddYYYY
subsidiaries as identified on the included schedule showing the names and
Revenue ID numbers of all subsidiaries.
(B)
(C)
(D)
Name and address of each shareholder, member or partner having an inter-
Social Security
We, the undersigned
(A)
Number or Federal
Percentage
shareholders, consent to the
est in the corporation’s stock without regard to the manner in which the
Employer
of
election of the corporation not
stock is owned. If additional space is needed, complete a separate sched-
Identification
Stock
to be taxed as a
ule and include it with this form.
Number
Pennsylvania S corporation.
Owned
You must provide your Social Security number so the department may
establish your identity and cross-reference other tax systems, as is author-
ized under federal law, 42 U.S.C. § 405 (c).
MMDDYYYY
Name
Signature/date
Street
Ci t y
State
ZIP Cod e
Please Sign after printing.
MMDDYYYY
Name
Signature/date
Street
Ci t y
State
ZIP Cod e
Please Sign after printing.
MMDDYYYY
Name
Signature/date
Street
Ci ty
State
ZIP Cod e
Please Sign after printing.
MMDDYYYY
Name
Signature/date
Street
Ci t y
State
ZIP Cod e
Please Sign after printing.
MMDDYYYY
Name
Signature/date
Street
Ci t y
State
ZIP Cod e
Please Sign after printing.
MMDDYYYY
Name
Signature/date
Street
Ci t y
State
ZIP Code
Please Sign after printing.
MMDDYYYY
Name
Signature/date
Street
Ci t y
State
ZIP Cod e
Please Sign after printing.
MMDDYYYY
Name
Signature/date
Street
Ci t y
State
ZIP Cod e
Please Sign after printing.
Total = _____ 100%
the corporate statement must be signed by an authorized officer of the corporation. the
NAME OF CORPORAtE OFFICER
tELEPHONE NUMBER
above-named corporation hereby elects not to be taxed as a Pennsylvania S corporation
under Section 401 of the tax Reform Code of 1971.
SIGNAtURE ANd tItLE
Please Sign after printing.
Under penalties of perjury, I declare that I have examined this Election Not To Be
SOCIAL SECURItY NUMBER
dAtE
Taxed As A Pennsylvania S Corporation, and to the best of my knowledge and belief
MMDDYYYY
it is true, correct and complete.
Reset Entire Form
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