Form Rev-1705r - Tax Account Information Change/correction Form

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TA X A C C O U N T I N F O R M AT I O N C H A N G E / C O R R E C T I O N F O R M

REV-1705R AS (7-10) (FI)

SECTION I.

If your EIN was changed by the IRS, you must complete a new registration form (PA-100). SALES/USE TAX, PTA, VRT AND CIGARETTE DEALER’S LICENSES ARE NON-TRANSFERABLE.

EXISTING TAX ACCOUNT ID

ENTITY ID (EIN/SSN)

CORRECT ENTITY ID (EIN/SSN)

CURRENT FILING STATUS

CHANGE FILING STATUS TO: (CHECK ONLY ONE –

MORE FREQUENT FILING STATUS ONLY)

SALES:

MONTHLY

QUARTERLY

SECTION II.

EXISTING LEGAL NAME/TRADE NAME/ADDRESS

NEW LEGAL NAME/TRADE NAME/ADDRESS

EMPLOYER:

SEMIMONTHLY

MONTHLY

LEGAL

SEMIWEEKLY

NAME

SECTION III. ADD LOCAL SALES TAX

TRADE

NAME

COUNTY:

DATE OF FIRST SALE IN COUNTY:

MONTH

DAY

YEAR

PRIMARY

ALLEGHENY

ADDRESS

PHILADELPHIA

SECTION IV. OTHER TAX CHANGES

LOCATION

TYPE OF TAX:

ACCOUNT ID NUMBER:

ADDRESS

SALES/USE TAX

(NO PO BOX)

EMPLOYER TAX

MAILING

PTA TAX

VRT

ADDRESS

CIGARETTE

SECTION V.

INDIVIDUAL OWNER(S), PARTNER(S) OR CORPORATE OFFICER(S) RESPONSIBLE FOR RETURN INFORMATION. Ownership change requires a new registration form (PA-100).

NAME

SSN

NAME

SSN

MAIL TO:

PA DEPARTMENT OF REVENUE

DATE

DAYTIME TELEPHONE

EXT.

SIGNATURE/TITLE

E-MAIL ADDRESS

PO BOX 280901