Form Rev-1706 As - Business/account Cancellation Form

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REV-1706 AS (04-10)
BUSINESS/ACCOUNT CANCELLATION FORM
LEGAL NAME:
TRADE NAME:
ENTITY ID (EIN/SSN):
SECTION I.
STATE/LOCAL SALES TAX LICENSE CANCELLATION INFORMATION
Sales Tax License is Non–Transferable
SALES TAX ACCOUNT ID
BUSINESS DISCONTINUED
NO TAXABLE SALES FOR:
REPORTING AND PAYING UNDER
OTHER REASONS:
ANOTHER ACCOUNT ID NUMBER:
STATE/LOCAL TAX
STATE/LOCAL TAX AFTER
DATE
STATE/LOCAL TAX
PHILADELPHIA LOCAL TAX
PHILADELPHIA LOCAL TAX AFTER
DATE
ACCOUNT ID
ALLEGHENY COUNTY LOCAL TAX
ALLEGHENY COUNTY LOCAL TAX AFTER
DATE
SECTION II.
EMPLOYER WITHHOLDING TAX CANCELLATION INFORMATION
EMPLOYER WITHHOLDING TAX
REASON FOR CANCELLATION:
REPORTING AND PAYING UNDER
ACCOUNT ID
ANOTHER ACCOUNT ID NUMBER:
BUSINESS CLOSED OR SOLD
DATE
EMPLOYER WITHHOLDING TAX
NO LONGER HAS EMPLOYEE(S) SUBJECT TO PA PERSONAL INCOME TAX
DATE
ACCOUNT ID
OTHER
DATE
SECTION III.
PUBLIC TRANSPORTATION ASSISTANCE FUND TAXES AND FEES/VEHICLE RENTAL TAX INFORMATION
PTA License is Non –Transferable
PTA TAX ACCOUNT ID
BUSINESS DISCONTINUED
REPORTING AND PAYING UNDER
VEHICLE RENTAL TAX INFORMATION:
ANOTHER ACCOUNT ID NUMBER:
PTA TAX ACCOUNT ID
SALES TAX ACCOUNT ID
DATE
VRT ACCOUNT ID
BUSINESS DISCONTINUED DATE
SECTION IV.
CIGARETTE DEALER’S LICENSE CANCELLATION INFORMATION
Cigarette Dealer’s License is Non-Transferable
CIGARETTE DEALER’S LICENSE NUMBER
NAME
SSN
MAIL TO:
PA DEPARTMENT OF REVENUE
DATE
DAYTIME TELEPHONE
EXT.
SIGNATURE/TITLE
E-MAIL ADDRESS
PO BOX 280901
(
)
PLEASE SIGN AFTER PRINTING
HARRISBURG, PA 17128-0901
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