Form Rev-291 Ex - Nonwithholding Of Pa Income Tax Application

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REV-291 EX (04-12)
NONWITHHOLDING OF
PA INCOME TAX APPLICATION
PURPOSE OF REV-291
Withholding Required. A partnership or PA S corporation is required to withhold Pennsylvania personal income tax on the PA-source
income of each nonresident partner, member or shareholder. Exception. A partnership or PA S corporation is not required to withhold
Pennsylvania personal income tax on income from a partner, member or shareholder if the partner or shareholder is one of the
following and gives the partnership or PA S corporation a completed and a signed REV-291, Nonwithholding of PA Income Tax Application:
A PA S corporation or other corporation
A clearing agency (or its nominee) or a broker or financial
institution (or its nominee) that holds an interest in a
A partnership or other unincorporated enterprise
partnership or PA S corporation as a nominee on behalf of one
A pension, profit-sharing or charitable trust
of the above.
A resident individual, estate or trust
This application should be filed with the partnership or PA S corporation. Do not submit this form to the department.
Part 1
IDENTIFICATION
START
1a. Name of beneficial owner of partnership or PA S corporation interest
1b. Taxpayer Identification Number
9 DIGIT - NO DASH
1c. Permanent street address
Address
City
State
ZIP Code
1d. Current mailing address, if different than permanent street address (include apartment or suite number or post office box if mail is not
delivered to street address).
Address
City
State
ZIP Code
1e. Withholding agent (enter name of partnership or PA S corporation)
1f. Taxpayer Identification Number
9 DIGIT - NO DASH
1g. Current mailing address (include apartment or suite number or post office box if mail is not delivered to street address).
Address
City
State
ZIP Code
COMPLETE PART 2 OR PART 3
Part 2
CERTIFICATION BY BENEFICIAL OWNER
The beneficial owner of an interest in the withholding agent is (check applicable block):
o
A PA S corporation or other corporation
o
A pension, profit-sharing or charitable trust, a business trust, a partnership or other unincorporated enterprise
o
A resident individual, estate or trust
Part 3
CERTIFICATION BY NOMINAL OWNER
3a. Name of nominal owner of partnership or PA S corporation interest
3b. Taxpayer Identification Number
9 DIGIT - NO DASH
3c. Current mailing address (include apartment or suite number or post office box if mail is not delivered to street address).
Address
City
State
ZIP Code
3d. The nominal owner holds its interest in withholding agent as a nominee on behalf of the beneficial owner. The beneficial owner is
(check applicable block):
o
A PA S corporation or other corporation
o
A pension, profit-sharing or charitable trust, a business trust, a partnership or other unincorporated enterprise
o
A resident individual, estate or trust
Part 4
REVOCATION OR TERMINATION OF PRIOR WITHHOLDING EXEMPTION CERTIFICATE
o
Check this box if you are revoking a prior Nonwithholding of PA Income Tax Application.
Under penalties of perjury, I certify that to the best of my knowledge and belief the information entered on this form is correct.
Print or type name of beneficial owner or authorized representative.
MM/DD/YY
Signature
Date
Please Sign Your Return after printing.
PRINT FORM
Reset Entire Form

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