Keystone Opportunity Zone - Program Guidelines And Application - Pennsylvania Department Of Community And Economic Development Page 12

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Application Number
For Department Use
20
Keystone Opportunity Zone (KOZ)
pennsylvania
PA
Application
D E P A R T M E N T O F C O M M U N I T Y
E C O N O M I C D E V E L O P M E N T
&
* Indicates required field
c Real Property Owner
c Business
c Resident
1. *Is this application for benefits for a
:
(check all that apply)
2. *Name of Real Property Owner/Business/Resident:
3. CEO or President of Business:
4. *KOZ Address of Business/Resident/Property Owner:
City:
State:
Zip:
5. *Municipality:
County:
County Code#:
*School District:
School District Code#:
6. Property Tax Parcel ID Number(s), if applicable:
7. *Mailing Address
:
(where correspondence concerning KOZ issues should be mailed)
City:
State:
Zip:
8. *Contact Name:
Telephone #:
Fax #:
E-mail address:
9. SS Number
: __ __ __ - __ __ - __ __ __ __
(i.e. property owner, resident or sole proprietorship)
Spouse’s SS Number: __ __ __ - __ __ - __ __ __ __
10. Tax ID Numbers: (MUST be provided, if applicable)
EIN __ __ - __ __ __ __ __ __ __ Sales Tax __ __ - __ __ __ __ __ __ Employer Acct
. (not EIN)
Corporate Box:
Utility PURTA :
Unemployment Compensation:
11. Business Only: Indicate how your entity reports to the Internal Revenue Service (Check type of entity):
c LLC
c C Corp
c S Corp
c Non-Profit
c Partnership
c Trust/Estate
is the LLC a:
c Partnership: Form 1065
c C Corporation: Form 1120
c S Corporation: Form 1120S
c Disregarded Entity (Corporate): Form 1120
c Disregarded Entity (Sole Proprietorship): Form 1040
Other
:
(please specify type)
9

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