REV-181 CM (09-13) DEPARTMENT USE ONLY Bureau of Compliance PO BOX 280947 Harrisburg PA 17128-0947 1 2 Name of Business APPLICATION FOR TAX CLEARANCE CERTIFICATE NO FILING FEE REVENUE ID Please Type or Print Federal EIN Location of Business (Current Mailing Address) P.O. Box, Street and Number or R.D. Number and Box Number City or Town County Telephone Number State ZIP Code 3 Name, Address and Phone Number of Attorney or Representative to whom Clearance Certificate should be sent (if different from #2) Name P.O. Box, Street and Number or R.D. Number and Box Number City or Town County State ZIP Code Telephone Number 4 Name ( s), Home Address(es) and Social Security Number(s) of Sole Proprietor, General Partners, Business Trustee, President and Treasurer of the Corporation or Chief Executive Officer or Majority Owner of Entity. (Attach listing if necessary.) Name Social Security Number Telephone Number P.O. Box, Street and Number or R.D. Number and Box Number Name P.O. Box, Street and Number or R.D. Number and Box Number City Social Security Number City State Telephone Number State ZIP Code ZIP Code 5 Type of Business DOMESTIC CORPORATION (Incorporated in PA) PARTNERSHIP ASSOCIATION LIMITED LIABILITY PARTNERSHIP If Domestic Corporation, give incorporation date. FOREIGN CORPORATION (not incorporated in PA) PROPRIETORSHIP BUSINESS TRUST OTHER (Specify) NONPROFIT CORPORATION (Please submit copy of 501(c) exemption letter) LIQUIDATING TRUST LIMITED LIABILITY COMPANY If Foreign Corporation, give state where incorporated and date of Certificate of Authority in PA. Registered Pennsylvania Address, P.O. Box, Street and Number City or Town Date business started in Pennsylvania 6 County Date terminated State ZIP Code Describe the business activity in Pennsylvania, including services performed and rendered, and give principal commodity sold at wholesale or retail. If sales or construction are involved, please explain. If manufacturer's representatives or independent contractors perform activities, render services or execute sales on behalf of the entity rather than entity's employees, please specify what activities were performed, what services were rendered and what type of sales were executed. 7 Did the entity have employees for which PA personal income tax was required to be withheld from wages? 8 Did taxpayer ever hold any of the following licenses, permits or accounts with the Commonwealth of PA? to (a) Corporation Tax Yes No Period to (b) Malt Beverage or Liquor License Yes No Period to (c) Liquid Fuels Yes No Period to (d) Cigarette Tax Yes No Period to (e) Sales, Use and Hotel Occ. Tax Yes No Period to (f) Motor Carrier Yes No Period to (g) Fuel Dealer-User Yes No Period to (h) Lottery Yes No Period to (i) Small Games of Chance Mfg. / Distr. Yes No Period to (j) Public Transportation Assistance Yes No Period to (k) PA Unemployment Compensation Yes No Period to (l) PA Oil Company Franchise Tax Yes No Period Revenue ID No. License No. Permit No. License No. License No. License No. License No. Agent No. License No. License No. Account No. Account No. American LegalNet, Inc. www.FormsWorkFlow.com Page 2 9 Were the assets or activities of the business acquired in whole or in part from a prior business entity? Yes No ( If "Yes", give predecessor's name, address and acquisition date. ) Name P.O. Box, Street and Number City or Town County State Yes Acquisition Date ZIP Code No 10 Has the business held title to any real estate in the last five years from the date of this application? l If "Yes", complete Schedule A (last page). l If you currently hold title to real estate in PA, complete Schedule B (last page). 11 Will the assets or activities of the business be transferred to another? A. B. C. D. E. Corporation Partnership Proprietorship Liquidating Trust Association Yes Yes Yes Yes Yes No No No No No F. Other Explain: Yes No If "Yes", complete: Name of New Owner Street Address of New Owner City State ZIP Code 12 Purpose of Clearance Certificate (check appropriate block): A. Dissolution of Corporation or Association through Department of State. B. Dissolution of Corporation or Association through Court of Common Pleas. Date Court was petitioned and county: (date) C. Withdrawal of Foreign Corporation through Department of State D. Merger or consolidation of two or more Corporations or Associations where surviving Corporation or Association is not subject to the jurisdiction of Pennsylvania. (See 15 Pa C.S. § 139.) E. Bulk Sale Clearance Certificate under Section 1403 of the Fiscal Code. Sale date: Copy of settlement statement: Corporation Tax Purposes Employer Withholding Tax Purposes Sales, Use and Hotel Occupancy Tax Purposes (county) Unemployment Compensation Tax Purposes STATEMENT OF AUTHORIZATION I authorize the PA Department of Revenue to disclose, verbally or in written form, all tax filings, payments or delinquencies requested by the buyer or his representatives for the bulk sale transfer provision. Authorized by Title Date F. Foreign Corporation Clearance Certificate under the provisions of the Act of 1947, P.L. 493, Contract Number and Political Subdivision: 13 Location of business records, available for audit of Pennsylvania operations. P.O. Box, Street and Number Telephone Number City State ZIP Code 14 List any matters pending with the PA Department of Revenue (e.g. petitions, appeals): 15 Did the business ever, within the Commonwealth of PA: (a) Engage in the sale of soft drinks or soft drink syrup ........................................................ (b) Own or lease and operate diesel-powered motor vehicles on PA highways?.................... (c) Engage in the sale of diesel fuel to motor vehicles using PA highways? .......................... (d) Engage in the sale or lease of tangible personal property since Sept. 1, 1953? .............. (e) File PA Unemployment Compensation Reports?................................................................ If "Yes", give Account Number (See question 8k.) Yes Yes Yes Yes Yes No No No No No Period Period Period Period Period to to to to to 16 Have you terminated your business activities in Pennsylvania? Yes No l If "Yes", give distribution of assets date: l If "No", explain: l If a Foreign Corporation, have you terminated business in the state of your incorporation? Yes No American LegalNet, Inc. www.FormsWorkFlow.com Page 3 17 Number of employees and total gross payrolls during the last five operating years (as reported to the Soci