Keystone Opportunity Zone - Program Guidelines And Application - Pennsylvania Department Of Community And Economic Development Page 14
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17Keystone Opportunity Zone
pennsylvania
PA
20
Change of Status Notification
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
&
This form needs to be completed if a KOZ applicant is receiving or has received KOZ benefits and there is a
change in the status.
1. KOZ File Number
:
(8 digit number assigned by DCED)
2. KOZ Applicant Name
:
(as listed on original application)
3. KOZ Address:
4. KOZ Parcel Number(s):
5. Contact Name: Mr./Mrs./Ms.
6. Mailing Address:
7. Effective Date of Change:
8. Choose a Reason and Explain:
¨ Relocation; ¨ Sale; ¨ Closure; ¨ Local non-compliance; ¨ Death; ¨ Business name change;
¨ Application type change (i.e. Business becomes property owner only, parcel number change, address
change.)
Please mail completed notification to:
Pennsylvania Department of Community & Economic Development
Tom Usiadek
Keystone Opportunity Zone Manager
400 North Street, 4th Floor
Commonwealth Keystone Building
Harrisburg, Pennsylvania 17120-0225
11
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