Form 83-T-104a - Application For Individual Philadelphia City Wage Tax Account Number

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A
I
PPLICATION FOR
NDIVIDUAL
P
C
W
T
A
N
HILADELPHIA
ITY
AGE
AX
CCOUNT
UMBER
CITY OF PHILADELPHIA • D E P A R T M E N T
O F
R E V E N U E
PUBLIC
SERVICE
CONCOURSE
•
1401
JOHN
F.
KENNEDY
BOULEVARD
PHILADELPHIA,
PA
19102
(215) 686-6600
NAME
SOCIAL SECURITY NUMBER
LAST
FIRST
M.I.
HOME ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE NUMBER (Including Area Code)
OCCUPATION
(
)
EMPLOYER'S NAME
STARTING DATE
EMPLOYER'S ADDRESS
CITY
STATE
ZIP CODE
ARE YOU STILL EMPLOYED?
YES
NO
(IF NO, INDICATE SEPARATION DATE) ____________________________
DATE
I
UNDERSTAND
THAT
IF
I
KNOWINGLY
MADE
ANY
FALSE
STATEMENT
HEREIN,
I
AM
SUBJECT
TO
SUCH
PENALTIES
AS
MAY
BE
PRESCRIBED
BY
LAW.
____________________________________________________
___________________________
Signature
Date
COMPLETE THE BOTTOM PORTION IF REMITTANCE IS ACCOMPANYING APPLICATION
E
Q
W
T
R
M P LO Y E E
U A RT E R LY
A G E
A X
E T U R N
NAME
SOCIAL SECURITY NUMBER
ADDRESS
ENTER TAX QUARTER
(CHECK):
1 .
JANUARY-MARCH
2.
APRIL-JUNE
3.
JULY-SEPTEMBER
4.
OCTOBER-DECEMBER
1. TAXABLE EARNINGS THIS QUARTER
( I n c l u d e T i p s I f A p p l i c a b l e )
2. RESIDENTS BLOCK #1 x TAX RATE
( S e e R e v e r s e )
3. NON-RESIDENTS BLOCK #1 x TAX RATE
( S e e R e v e r s e )
4. INTEREST & PENALTY
(See Reverse)
5 . TOTALS
( B l o c k s 2 , 3 , & 4 )
83-T-104A (Rev. 7/99)

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