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

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REV-976 (08-11)
BUREAU OF CORPORATION TAXES
PA S UNIT
ELECTION NOT TO BE TAXED AS
PO BOX 280705
HARRISBURG PA 17128-0705
A PENNSYLVANIA S CORPORATION
Corporation is not subject to
PA corporate taxes; election is for PA
resident shareholder purposes only.
Tax Account ID
Federal ID (EIN)
Election is to be first effective for:
Tax year beginning:
month / day / year
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:
month / day / year
subsidiaries as identified on the attached schedule showing the names
and Tax Account ID numbers of all subsidiaries.
(B)
(C)
(D)
Social Security
We, the undersigned
(A)
Name and address of each shareholder, member or partner having an
Number or Federal
Percentage
shareholders, consent to the
interest in the corporation’s stock without regard to the manner in which
Employer
of
election of the corporation not
the stock is owned. If additional space is needed, complete a separate
Identification
Stock
to be taxed as a
schedule and attach it to this form.
Number
Owned
Pennsylvania S corporation.
The department is authorized under federal law, 42 U.S.C. § 405 (c), to
use your Social Security number in administering state tax law.
Disclosure of your Social Security number is mandatory and will be used
to establish your identity and cross-reference with other tax systems.
Name
Signature/Date
Street
Ci t y
State
ZIP Cod e
Name
Signature/Date
Street
Ci t y
State
ZIP Cod e
Name
Signature/Date
Street
Ci ty
State
ZIP Cod e
Name
Signature/Date
Street
Ci t y
State
ZIP Cod e
Name
Signature/Date
Street
Ci t y
State
ZIP Cod e
Name
Signature/Date
Street
Ci t y
State
ZIP Code
Name
Signature/Date
Street
Ci t y
State
ZIP Cod e
Name
Signature/Date
Street
Ci t y
State
ZIP Cod e
Total = _____ 100%
NAME OF CORPORATE OFFICER
TELEPHONE NUMBER
The corporate statement must be signed by an authorized officer of the corpora-
tion. The above-named corporation hereby elects not to be taxed as a
Á
Pennsylvania S corporation under Section 401 of the Tax Reform Code of 1971.
SIGNATURE AND TITLE
Under penalties of perjury, I declare that I have examined this Election Not
SOCIAL SECURITY NUMBER
DATE
To Be Taxed As A Pennsylvania S Corporation form, and to the best of my
knowledge and belief it is true, correct and complete.

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