PA-100 (03-09) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE BUREAU OF BUSINESS TRUST FUND TAXES PO BOX 280901 HARRISBURG, PA 17128-0901 Go Paperless . . . REGISTER ON THE INTERNET www.paopenforbusiness.state.pa.us P E N N S Y LVA N I A ENTERPRISE REGISTRATION F O R M AN D I N STR U CTI O N S AUXILIARY AIDS AND SERVICES ARE AVAILABLE UPON REQUEST TO INDIVIDUALS WITH DISABILITIES. EQUAL OPPORTUNITY EMPLOYER/PROGRAM. DETACH AND MAIL COMPLETED REGISTRATION FORM TO: COMMONWEALTH OF PA • DEPARTMENT OF REVENUE • BUREAU OF BUSINESS TRUST FUND TAXES • PO BOX 280901 • HARRISBURG, PA 17128-0901 American LegalNet, Inc. www.FormsWorkFlow.com P E N N S Y LVA N I A E N T E R P R I S E R E G I S T R AT I O N The Pennsylvania Enterprise Registration Form (PA-100) must be completed by enterprises to register for certain taxes and services administered by the PA Department of Revenue and the PA Department of Labor & Industry. The form is also designed to be used by previously registered enterprises to register for additional taxes and services, reactivate a tax or service, or notify both Departments that additional establishment locations have been added. The form is also used to request the Unemployment Compensation Experience Record and Reserve Account Balance of a Predecessor. For registration assistance, contact: (717) 787-1064, Monday through Friday 8 AM to 4:30 PM (EST); Service for Customers with special hearing and/or speaking needs (TT only) 1-800-447-3020. What is an enterprise? An enterprise is any individual or organization, sole-proprietorship, partnership, corporation, government organization, business trust, association, etc., which is subject to the laws of the Commonwealth of Pennsylvania and performs at least one of the following: Pays wages to employees Offers products for sale to others Offers services for sale to others Collects donations Collects taxes Is allocated use of tax dollars Has a name which is intended for use and, by that name, is to be recognized as an organization engaged in economic activity. How to complete the registration form: New registrants must complete every item in Sections 1 through 10 and additional sections as indicated. Registered enterprises must complete every item in Sections 1 through 6 and additional sections as indicated. Section 5 has indicators to direct the registrant to additional sections. To determine the registration requirements for a specific tax service and/or license, see pages 2 and 3. Type or print legibly using black ink. Enter all dates in MM/DD/YYYY format (E.G. 01/01/2005). Retain a copy of the completed registration form for your records. What is an establishment? An establishment is an economic unit, generally at a single physical location where: Business is conducted inside PA Business is conducted outside PA with reporting requirements to PA PA residents are employed, inside or outside of PA. The enterprise and the establishment may have the same physical location. Multiple establishments exist if the following apply: Business is conducted at multiple locations. Distinct and separate economic activities involving separate employees are performed at a single location. Each activity may be treated as a separate establishment as long as separate reports can be prepared for the number of employees, wages and salaries, or sales and receipts. How to avoid delays in processing: Review the registration form and accompanying sections to be sure that every item is complete. The preparer will be contacted to supply information if required sections are not completed. Enclose payment for license or registration fees, payable to PA Department of Revenue. If a quarterly UC Report/payment is submitted, attach a separate check payable to PA Unemployment Compensation Fund. Sign the registration form. Remove completed pages from the booklet, arrange in sequential order, and mail to the PA Department of Revenue. It is your responsibility to notify the Bureau of Business Trust Fund Taxes in writing within 30 days of any change to the information provided on the registration form. Completing this form will NOT fulfill the requirement to register for corporate taxes. Registering corporations must contact the PA Department of State to secure corporate name clearance and register for corporation tax purposes. Contact the PA Department of State at (717) 787-1057, or visit www.paopenforbusiness.state.pa.us. TA B L E O F C O N T E N T S Section Form Page Inst. Page Section Form Page Inst. Page Mailing Address . . . . . . . . . . . . . . . . . . . . . . . . . . .Front Cover 13 Government Structure . . . . . . . . . . . . . . . . . . . . .7 . . . . . . .23 Taxes and Services (definitions & requirements) . . . . . . . . .2-3 14 Predecessor/Successor Information . . . . . . . . . .8 . . . . . . .23 1 Reason for this Registration . . . . . . . . . . . . . . . .4 . . . . . . .18 15 2 Enterprise Information . . . . . . . . . . . . . . . . . . . . .4 . . . .18-19 Application for PA UC Experience Record & . . . .9 . . . . . . .23 Reserve Account Balance of Predecessor 3 Taxes & Services . . . . . . . . . . . . . . . . . . . . . . . . .4 . . . . . . .19 16 4 Authorized Signature . . . . . . . . . . . . . . . . . . . . . .4 . . . . . . .19 Unemployment Compensation Partial . . . . . . . . .9 . . . . . . .24 Transfer Information 5 Business Structure . . . . . . . . . . . . . . . . . . . . . . . .5 . . . . . . .19 17 Multiple Establishment Information . . . . . . . . . . .10-11 . . . .24 6 Owners, Partners, Shareholders, Officers, . . . . .5 . . . . . . .19 Responsible Party Information 18 6a Additional Owners, Partners, Shareholders, . . . .11 . . . . . .19 Officers, Responsible Party Information Sales Use and Hotel Occupancy Tax License, . .12 . . .24-25 Public Transportation Assistance Tax License, Vehicle Rental Tax, Transient Vendor Certificate, Promoter License, or Wholesaler Certificate 19 Cigarette Dealerʼs License . . . . . . . . . . . . . . . . . .13 . . . . . .25 7 Establishment Business Activity Information . . . .5 . . . .20-21 20 Small Games of Chance License/Certificate . . . .14-15 . . .25 8 Establishment Sales Information . . . . . . . . . . . . .6 . . . . . . .22 9 Establishment Employment Information . . . . . . . .6 . . . . . . .22 21 Motor Carrier Registration & Decal/Motor . . . . . .16 . . .25-26 Fuels License & Permit 10 Bulk Sale/Transfer Information . . . . . . . . . . . . . .6 . . . . . . .22 22 11 Corporation Information . . . . . . . . . . . . . . . . . . . .7 . . . . . . .22 Sales Tax Exempt Status for Charitable and . . . .17 . . . . . .26 Religious Organizations 12 Reporting & Payment Methods . . . . . . . . . . . . . .7 . . . . . . .22 Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26-27 1 American LegalNet, Inc. www.FormsWorkFlow.com THE FOLLOWING CHART WILL HELP DETERMINE THE SECTIONS OF THIS BOOKLET THAT SHOULD BE COMPLETED FOR VARIOUS TAX TYPES. COMPLETE THE SECTIONS THAT APPLY TO YOUR ENTERPRISE. New registrants should complete Sections 1 through 10 plus the sections indicated. Previous registrants should complete Sections 1 through 6 plus the additional sections indicated. TAXES AND SERVICES CIGARETTE TAX IS AN EXCISE TAX IMPOSED ON THE SALE OR POSSESSION OF CIGARETTES. A DEALER IS ANY CIGARETTE STAMPING AGENT, WHOLESALER, OR RETAILER. CORPORATE NET INCOME AND CAPITAL STOCK FRANCHISE TAXES ARE IMPOSED ON DOMESTIC AND FOREIGN CORPORATIONS, CERTAIN BUSINESS TRUSTS, AND LIMITED LIABILITY COMPANIES WHICH ARE REGISTERED AND/OR TRANSACTING BUSINESS WITHIN THE COMMONWEALTH OF PENNSYLVANIA. SUBJECTIVITY TO SPECIFIC CORPORATION TAXES IS DETERMINED BY THE TYPE OF CORPORATE ORGANIZATION AND THE ACTIVITY CONDUCTED. REQUIREMENTS SECTIONS TO COMPLETE CIGARETTE DEALERʼS LICENSE SECTION 19 SALES TAX LICENSE (RETAILER) SECTION 18 REGISTRATION WITH PA DEPARTMENT OF STATE FORMS MUST BE OBTAINED FROM PA DEPARTMENT OF STATE FINANCIAL INSTITUTIONS TAXES: THE BANK AND TRUST COMPANY SHARES TAX IS IMPOSED ON EVERY BANK AND TRUST COMPANY HAVING CAPITAL STOCK AND CONDUCTING BUSINESS IN PENNSYLVANIA. DOMESTIC TITLE INSURANCE COMPANIES ARE SUBJECT TO THE TITLE INSURANCE COMPANY SHARES TAX. THE MUTUAL THRIFT INSTITUTIONS TAX IS IMPOSED ON SAVINGS INSTITUTIONS, SAVINGS BANKS, SAVINGS AND LOAN ASSOCIATIONS, AND BUILDING AND LOAN ASSOCIATIONS CONDUCTING BUSINESS IN PENNSYLVANIA. CREDIT UNIONS ARE NOT SUBJECT TO TAX. REGISTRATION WITH FEDERAL OR STATE AUTHORITY THAT GRANTED CHARTER GROSS PREMIUMS TAX IS LEVIED ON DOMESTIC AND FOREIGN INSURANCE COMPANIES. THE YEARLY GROSS PREMIUMS RECEIVED FORM THE TAX BASE. GROSS PREMIUMS ARE PREMIUMS, PREMIUM DEPOSITS, OR ASSESSMENTS, FOR BUSINESS TRANSACTED IN PENNSYLVANIA. REGISTRATION WITH PA DEPARTMENT OF INSURANCE GROSS RECEIPTS TAX IS LEVIED ON PIPELINE, CONDUIT, WATER NAVIGATION AND TRANSPORTATION COMPANIES; TELEPHONE, TELEGRAPH AND MOBILE TELECOMMUNICATIONS COMPANIES; ELECTRIC LIGHT, WATER POWER AND HYDROELECTRIC COMPANIES; AND FREIGHT AND OIL TRANSPORTATION COMPANIES. SECTION 11 REGISTRATION WITH PA PUBLIC UTILITY COMMISSION THE TAX IS BASED ON GROSS RECEIPTS FROM PASSENGERS, BAGGAGE AND FREIGHT TRANSPORTED WITHIN PENNSYLVANIA; TELEGRAPH AND TELEPHONE MESSAGES TRANSMITTED WITHIN PENNSYLVANIA; AND SALES OF ELECTRICITY IN PENNSYLVANIA. PUBLIC UTILITY REALTY TAX IS LEVIED AGAINST CERTAIN ENTITIES FURNISHING UTILITY SERVICES. PENNSYLVANIA IMPOSES THIS TAX ON PUBLIC UTILITY REALTY IN LIEU OF LOCAL REAL ESTATE TAXES AND DISTRIBUTES THE LOCAL REALTY TAX EQUIVALENT TO LOCAL TAXING AUTHORITIES. REGISTRATION WITH PA PUBLIC UTILITY COMMISSION OTHER CORPORATION TAXES: THIS GROUP IS COMPOSED PRIMARILY OF THE CORPORATE LOANS TAX, THE COOPERATIVE AGRICULTURAL ASSOCIATION AND ELECTRIC COOPERATIVE CORPORATION TAXES. REGISTRATION WITH PA DEPARTMENT OF STATE EMPLOYER WITHHOLDING IS THE WITHHOLDING OF PENNSYLVANIA PERSONAL INCOME TAX BY EMPLOYERS FROM COMPENSATION PAID TO PENNSYLVANIA RESIDENT EMPLOYEES FOR WORK PERFORMED INSIDE OR OUTSIDE OF PENNSYLVANIA AND NONRESIDENT EMPLOYEES FOR WORK PERFORMED INSIDE PENNSYLVANIA. (SEE UNEMPLOYMENT COMPENSATION DEFINITION) LIQUID FUELS AND FUELS TAX IS AN EXCISE TAX IMPOSED ON ALL LIQUID FUELS AND FUELS USED OR SOLD AND DELIVERED BY DISTRIBUTORS WITHIN PENNSYLVANIA, EXCEPT THOSE DELIVERED TO EXEMPT PURCHASERS. LIQUID FUELS INCLUDE GASOLINE, GASOHOL, JET FUEL, AND AVIATION GASOLINE. FUELS INCLUDE CLEAR DIESEL FUEL AND KEROSENE. ADDITIONALLY, THE LIQUID FUELS AND FUELS TAX ACT TAXES ALTERNATIVE FUELS (i.e. HIGHWAY FUELS OTHER THAN LIQUID FUELS OR FUELS) AT A RETAIL/USE TAX LEVEL. MOTOR CARRIERS ROAD TAX IS IMPOSED ON MOTOR CARRIERS ENGAGED IN OPERATIONS ON PENNSYLVANIA HIGHWAYS. A MOTOR CARRIER IS ANY PERSON OR ENTERPRISE OPERATING A QUALIFIED MOTOR VEHICLE USED, DESIGNED, OR MAINTAINED FOR THE TRANSPORTATION OF PERSONS OR PROPERTY WHERE (A) THE POWER UNIT HAS TWO AXLES AND A GROSS OR REGISTERED GROSS WEIGHT GREATER THAN 26,000 POUNDS, (B) THE POWER UNIT HAS THREE AXLES OR MORE REGARDLESS OF WEIGHT, OR (C) VEHICLES ARE USED IN COMBINATION AND THE DECLARED COMBINATION WEIGHT EXCEEDS 26,000 POUNDS OR THE GROSS WEIGHT OF THE VEHICLES EXCEEDS 26,000 POUNDS. SECTION 9 LIQUID FUELS AND FUELS TAX PERMIT SECTION 21 IFTA LICENSE AND IFTA DECALS PA NON-IFTA VEHICLE REGISTRATION AND PA NONIFTA DECALS SECTION 21 2 American LegalNet, Inc. www.FormsWorkFlow.com PROMOTER IS ANY ENTERPRISE ENGAGED IN RENTING, LEASING, OR GRANTING PERMISSION TO ANY PERSON TO USE SPACE AT A SHOW FOR THE DISPLAY OR FOR THE SALE OF TANGIBLE PERSONAL PROPERTY OR SERVICES. PUBLIC TRANSPORTATION ASSISTANCE FUND TAX IS A TAX OR FEE IMPOSED ON EACH SALE IN PENNSYLVANIA OF NEW TIRES FOR HIGHWAY USE, ON THE LEASE OF MOTOR VEHICLES, AND ON THE RENTAL OF MOTOR VEHICLES. THE TAX IS ALSO LEVIED ON THE STATE TAXABLE VALUE OF UTILITY REALTY OF ENTERPRISES SUBJECT TO THE PUBLIC UTILITY REALTY TAX AND ON PETROLEUM REVENUE OF OIL COMPANIES. SECTION 18 PROMOTER LICENSE SALES USE AND HOTEL OCCUPANCY TAX LICENSE SECTION 18 PUBLIC TRANSPORTATION ASSISTANCE TAX LICENSE REPORTING AND PAYMENT METHODS OFFER THE ENTERPRISE THE ABILITY TO FILE CERTAIN TAX RETURNS AND MAKE ELECTRONIC PAYMENTS THROUGH THE ELECTRONIC TAX INFORMATION AND DATA EXCHANGE SYSTEM (e-TIDES) OR THE TELEFILE SYSTEM. ELECTRONIC PAYMENT MAY ALSO BE MADE THROUGH ELECTRONIC FUNDS TRANSFER (EFT) OR CREDIT CARD. UNEMPLOYMENT COMPENSATION (UC) WAGES MAY BE REPORTED VIA A MAGNETIC MEDIUM. IN CERTAIN INSTANCES, AN ENTERPRISE MAY ELECT TO FINANCE UC COSTS UNDER A REIMBURSEMENT METHOD RATHER THAN THE CONTRIBUTORY METHOD. AUTHORIZATION AGREEMENT SECTION 12 SALES TAX IS AN EXCISE TAX IMPOSED ON THE RETAIL SALE OR LEASE OF TAXABLE, TANGIBLE PERSONAL PROPERTY, AND ON SPECIFIED SERVICES. SALES USE AND HOTEL OCCUPANCY TAX LICENSE SECTION 18 HOTEL OCCUPANCY TAX IS AN EXCISE TAX IMPOSED ON EVERY HOTEL OR MOTEL ROOM OCCUPANCY LESS THAN 30 CONSECUTIVE DAYS. LOCAL SALES TAX MAY BE IMPOSED IN PHILADELPHIA OR ALLEGHENY COUNTIES, IN ADDITION TO THE STATE SALES AND USE TAX, ON THE RETAIL SALE OR USE OF TANGIBLE PERSONAL PROPERTY AND SERVICES AND ON HOTEL/MOTEL OCCUPANCIES. SALES USE AND HOTEL OCCUPANCY TAX LICENSE SECTION 18 SALES USE AND HOTEL OCCUPANCY TAX LICENSE SECTION 18 SALES TAX EXEMPT STATUS FOR CHARITABLE AND RELIGIOUS ORGANIZATIONS IS THE QUALIFICATION OF AN INSTITUTION OF PURELY PUBLIC CHARITY TO BE EXEMPT FROM SALES AND USE TAX ON THE PURCHASE OF TANGIBLE PERSONAL PROPERTY OR SERVICES FOR USE IN CHARITABLE ACTIVITY. CERTIFICATE OF EXEMPT SALES TAX STATUS SECTION 22 SMALL GAMES OF CHANCE IS THE REGULATION OF LIMITED GAMES OF CHANCE THAT QUALIFIED CHARITABLE AND NON-PROFIT ORGANIZATIONS CAN OPERATE IN PENNSYLVANIA. SMALL GAMES OF CHANCE DISTRIBUTOR LICENSE AND/OR MANUFACTURER REGISTRATION CERTIFICATE SECTION 20 TRANSIENT VENDOR IS ANY ENTERPRISE WHOSE BUSINESS STRUCTURE IS SOLE PROPRIETOR OR PARTNERSHIP, NOT HAVING A PERMANENT PHYSICAL BUSINESS LOCATION IN PENNSYLVANIA, WHICH SELLS TAXABLE, TANGIBLE PERSONAL PROPERTY OR PERFORMS TAXABLE SERVICES IN PENNSYLVANIA. TRANSIENT VENDOR CERTIFICATE SECTION 18 UNEMPLOYMENT COMPENSATION (UC) PROVIDES A FUND FROM WHICH COMPENSATION IS PAID TO WORKERS WHO HAVE BECOME UNEMPLOYED THROUGH NO FAULT OF THEIR OWN. CONTRIBUTIONS ARE REQUIRED TO BE MADE BY ALL EMPLOYERS WHO PAY WAGES TO INDIVIDUALS WORKING IN PA AND WHOSE SERVICES ARE COVERED UNDER THE UC LAW. THIS TAX MAY INCLUDE EMPLOYEE CONTRIBUTIONS WITHHELD BY EMPLOYERS FROM EACH EMPLOYEEʼS GROSS WAGES. (SEE EMPLOYER WITHHOLDING DEFINITION) APPLICATION FOR PA UC EXPERIENCE RECORD AND RESERVE ACCOUNT BALANCE ENABLES THE REGISTERING ENTERPRISE TO BENEFIT FROM A PREDECESSORʼS REPORTING HISTORY. REFER TO THE INSTRUCTIONS TO DETERMINE IF THIS IS ADVANTAGEOUS. USE TAX IS AN EXCISE TAX IMPOSED ON PROPERTY USED IN PENNSYLVANIA ON WHICH SALES TAX HAS NOT BEEN PAID. VEHICLE RENTAL TAX IS IMPOSED ON RENTAL CONTRACTS BY ENTERPRISES HAVING AVAILABLE FOR RENTAL: (1) 5 OR MORE MOTOR VEHICLES DESIGNED TO CARRY 15 OR LESS PASSENGERS, OR (2) TRUCKS, TRAILERS, OR SEMI-TRAILERS USED IN THE TRANSPORTATION OF PROPERTY. A RENTAL CONTRACT IS FOR A PERIOD OF 29 DAYS OR LESS. WHOLESALER CERTIFICATE PERMITS AN ENTERPRISE SOLELY ENGAGED IN SELLING TANGIBLE PERSONAL PROPERTY AND/OR SERVICES FOR RESALE. TO PURCHASE TANGIBLE PERSONAL PROPERTY OR SERVICES FOR RESALE TAX-FREE WHEN USED IN THE NORMAL COURSE OF THE ENTERPRISEʼS BUSINESS. APPLICATION FOR EXPERIENCE RECORD AND RESERVE ACCOUNT BALANCE OF PREDECESSOR SECTIONS 7, 9, IF APPLICABLE 10 AND 14 SECTIONS 14, 15. IF APPLICABLE, 16 USE TAX ACCOUNT SECTION 18 SALES USE AND HOTEL OCCUPANCY TAX LICENSE SECTION 18 PTA LICENSE SECTION 18 WHOLESALER CERTIFICATE WORKERSʼ COMPENSATION COVERAGE IS MANDATORY AND PROTECTS EMPLOYEES FROM WAGE LOSS BENEFITS AND MEDICAL EXPENSES INCURRED AS A RESULT OF JOB RELATED INJURIES OR DISEASES. EMPLOYERS THAT MAINTAIN WORKERSʼ COMPENSATION COVERAGE ARE IMMUNE TO LAWSUITS FLOWING FROM WORK-RELATED INJURIES OTHER THAN THOSE ACTIONS FILED UNDER THE WORKERSʼ COMPENSATION ACT. EVERY EMPLOYER LIABLE UNDER THE PA WORKERSʼ COMPENSATION ACT SHALL INSURE THE PAYMENT OF COMPENSATION WITH THE STATE WORKMENʼS INSURANCE FUND, OR WITH ANY PRIVATE INSURANCE COMPANY, OR MUTUAL ASSOCIATION OR COMPANY, AUTHORIZED TO INSURE SUCH LIABILITY IN THIS COMMONWEALTH OR BY SECURING THE AUTHORITY TO SELF-INSURE. UNLESS ALL EMPLOYEES ARE EXCLUDED FROM THE COVERAGE REQUIREMENTS, AND FALL INTO ONE OR MORE OF THE EXEMPT CATEGORIES, WORKERSʼ COMPENSATION MUST BE CONTINUALLY MAINTAINED WITH NO INTERRUPTION IN COVERAGE. 3 WORKERSʼ COMPENSATION COVERAGE SECTION 9 American LegalNet, Inc. www.FormsWorkFlow.com PA-100 (03-09) RECEIVED DATE COMMONWEALTH OF PENNSYLVANIA MAIL COMPLETED APPLICATION TO: DEPARTMENT OF REVENUE BUREAU OF BUSINESS TRUST FUND TAXES PO BOX 280901 HARRISBURG, PA 17128-0901 PA ENTERPRISE REGISTRATION FORM DEPARTMENT USE ONLY DEPARTMENT OF REVENUE & DEPARTMENT OF LABOR AND INDUSTRY TYPE OR PRINT LEGIBLY, USE BLACK INK SECTION 1 – REASON FOR THIS REGISTRATION REFER TO THE INSTRUCTIONS (PAGE 18) AND CHECK THE APPLICABLE BOX(ES) TO INDICATE THE REASON(S) FOR THIS REGISTRATION. 1. 2. 6. DID THIS ENTERPRISE: NEW REGISTRATION ADDING TAX(ES) & SERVICE(S) 3. YES INFORMATION UPDATE NO RESULT FROM A CHANGE IN LEGAL STRUCTURE (FOR EXAMPLE, FROM INDIVIDUAL PROPRIETOR TO CORPORATION, PARTNERSHIP TO CORPORATION, CORPORATION TO LIMITED LIABILITY COMPANY, ETC)? NO UNDERGO A MERGER, CONSOLIDATION, DISSOLUTION, OR OTHER RESTRUCTURING? ADDING ESTABLISHMENT(S) 5. NO ACQUIRE ALL OR PART OF ANOTHER BUSINESS? YES REACTIVATING TAX(ES) & SERVICE(S) 4. YES SECTION 2 – ENTERPRISE INFORMATION 1. DATE OF FIRST OPERATIONS 2. DATE OF FIRST OPERATIONS IN PA 3. ENTERPRISE FISCAL YEAR END 4. ENTERPRISE LEGAL NAME 5. FEDERAL EMPLOYER IDENTIFICATION NUMBER (EIN) 6. ENTERPRISE TRADE NAME (if different than legal name) 7. ENTERPRISE TELEPHONE NUMBER ( 8. ENTERPRISE STREET ADDRESS (do not use PO Box) CITY/TOWN ) COUNTY STATE ZIP CODE + 4 9. ENTERPRISE MAILING ADDRESS (if different than street address) CITY/TOWN STATE ZIP CODE + 4 10. LOCATION OF ENTERPRISE RECORDS (street address) CITY/TOWN STATE ZIP CODE + 4 11. ESTABLISHMENT NAME (doing business as) 12. NUMBER OF ESTABLISHMENTS * 13. PA SCHOOL DISTRICT 14. PA MUNICIPALITY * ENTERPRISES WITH ONE OR MORE ESTABLISHMENTS WITHIN PA, WHOSE PA ADDRESS WAS NOT ENTERED ABOVE, MUST COMPLETE SECTION 17. (SEE GENERAL INSTRUCTIONS AND SECTION 17 FOR MORE INFORMATION.) SECTION 3 – TAXES AND SERVICES ALL REGISTRANTS MUST CHECK THE APPLICABLE BOX(ES) TO INDICATE THE TAX(ES) AND SERVICE(S) REQUESTED FOR THIS REGISTRATION AND COMPLETE THE CORRESPONDING SECTIONS INDICATED ON PAGES 2 AND 3. IF REACTIVATING ANY PREVIOUS ACCOUNT(S), LIST THE ACCOUNT NUMBER(S) IN THE SPACE PROVIDED. PREVIOUS ACCOUNT NUMBER PREVIOUS ACCOUNT NUMBER CORPORATION TAXES SALES, USE, HOTEL OCCUPANCY TAX LICENSE EMPLOYER WITHHOLDING TAX SMALL GAMES OF CHANCE LIC./CERT. FUELS TAX PERMIT TRANSIENT VENDOR CERTIFICATE LIQUID FUELS TAX PERMIT UNEMPLOYMENT COMPENSATION MOTOR CARRIERS ROAD TAX/IFTA USE TAX CIGARETTE DEALERʼS LICENSE PROMOTER LICENSE VEHICLE RENTAL TAX PUBLIC TRANSPORTATION ASSISTANCE TAX LICENSE WHOLESALER CERTIFICATE SALES TAX EXEMPT STATUS WORKERSʼ COMPENSATION COVERAGE SECTION 4 – AUTHORIZED SIGNATURE I, (WE) THE UNDERSIGNED, DECLARE UNDER THE PENALTIES OF PERJURY THAT THE STATEMENTS CONTAINED HEREIN ARE TRUE, CORRECT, AND COMPLETE. AUTHORIZED SIGNATURE (ATTACH POWER OF ATTORNEY IF APPLICABLE) DAYTIME TELEPHONE NUMBER ( TYPE OR PRINT NAME E-MAIL ADDRESS TYPE OR PRINT PREPARERʼS NAME DAYTIME TELEPHONE NUMBER ( TITLE ) DATE TITLE E-MAIL ADDRESS DATE ) 4 American LegalNet, Inc. www.FormsWorkFlow.com PA-100 (03-09) DEPARTMENT USE ONLY ENTERPRISE NAME SECTION 5 – BUSINESS STRUCTURE CHECK THE APPROPRIATE BOX FOR QUESTIONS 1, 2 & 3. IN ADDITION TO SECTIONS 1 THROUGH 10, COMPLETE THE SECTION(S) INDICATED. 1. SOLE PROPRIETORSHIP (INDIVIDUAL) GENERAL PARTNERSHIP ASSOCIATION CORPORATION (Sec. 11) LIMITED PARTNERSHIP BUSINESS TRUST GOVERNMENT (Sec. 13) LIMITED LIABILITY PARTNERSHIP LIMITED LIABILITY COMPANY STATE WHERE CHARTERED ESTATE RESTRICTED PROFESSIONAL COMPANY STATE WHERE CHARTERED JOINT VENTURE PARTNERSHIP 2. PROFIT NON-PROFIT IS THE ENTERPRISE ORGANIZED FOR PROFIT OR NON-PROFIT? 3. YES NO IS THE ENTERPRISE EXEMPT FROM TAXATION UNDER INTERNAL REVENUE CODE (IRC) SECTION 501(c)(3)? IF YES, PROVIDE A COPY OF THE ENTERPRISE'S EXEMPTION AUTHORIZATION LETTER FROM THE INTERNAL REVENUE SERVICE. SECTION 6 – OWNERS, PARTNERS, SHAREHOLDERS, OFFICERS, AND RESPONSIBLE PARTY INFORMATION PROVIDE THE FOLLOWING FOR ALL INDIVIDUAL AND/OR ENTERPRISE OWNERS, PARTNERS, SHAREHOLDERS, OFFICERS, AND RESPONSIBLE PARTIES. IF STOCK IS PUBLICLY TRADED, PROVIDE THE FOLLOWING FOR ANY SHAREHOLDER WITH AN EQUITY POSITION OF 5% OR MORE. ADDITIONAL SPACE IS AVAILABLE IN SECTION 6A, PAGE 11. 1. NAME 5. 2. SOCIAL SECURITY NUMBER OWNER OFFICER PARTNER SHAREHOLDER RESPONSIBLE PARTY 6. TITLE 3. DATE OF BIRTH * 8. PERCENTAGE OF OWNERSHIP 7. EFFECTIVE DATE OF TITLE 4. FEDERAL EIN 9. EFFECTIVE DATE OF OWNERSHIP % 10. HOME ADDRESS (street) CITY/TOWN 11. THIS PERSON IS RESPONSIBLE TO REMIT/MAINTAIN: SALES TAX COUNTY STATE EMPLOYER WITHHOLDING TAX ZIP CODE + 4 MOTOR FUEL TAXES WORKERSʼ COMPENSATION COVERAGE * DATE OF BIRTH REQUIRED ONLY IF APPLYING FOR A CIGARETTE WHOLESALE DEALERʼS LICENSE, A SMALL GAMES OF CHANCE DISTRIBUTOR LICENSE, OR A SMALL GAMES OF CHANCE MANUFACTURER CERTIFICATE. SECTION 7 – ESTABLISHMENT BUSINESS ACTIVITY INFORMATION REFER TO THE INSTRUCTIONS ON PAGES 20 & 21 TO COMPLETE THIS SECTION. COMPLETE SECTION 17 FOR MULTIPLE ESTABLISHMENTS. 1. ENTER THE PERCENTAGE THAT EACH PA BUSINESS ACTIVITY REPRESENTS OF THE TOTAL RECEIPTS OR REVENUES AT THIS ESTABLISHMENT. LIST PRODUCTS OR SERVICES ASSOCIATED WITH EACH BUSINESS ACTIVITY AND THE PERCENTAGE REPRESENTING THE TOTAL RECEIPTS OR REVENUES. PA BUSINESS ACTIVITY % Accommodation & Food Services Agriculture, Forestry, Fishing, & Hunting Art, Entertainment, & Recreation Services Communications/Information Construction (must complete question 3) Domestics (Private Households) Educational Services Finance Health Care Services Insurance Management, Support & Remediation Services Manufacturing Mining, Quarrying, & Oil/Gas Extraction Other Services Professional, Scientific, & Technical Services Public Administration Real Estate Retail Trade Sanitary Service Social Assistance Services Transportation Utilities Warehousing Wholesale Trade TOTAL % ADDITIONAL PRODUCTS OR SERVICES 100% PRODUCTS OR SERVICES % 2. ENTER THE PERCENTAGE THAT THIS ESTABLISHMENTʼS RECEIPTS OR REVENUES REPRESENT OF THE TOTAL PA RECEIPTS OR REVENUES OF THE ENTERPRISE. ______________ %. SINGLE ESTABLISHMENT ENTERPRISES ENTER 100%. MULTIPLE ESTABLISHMENT ENTERPRISES ENTER PERCENTAGE OF ENTERPRISE (SEE SECTION 17). 3. ESTABLISHMENTS ENGAGED IN CONSTRUCTION MUST ENTER THE PERCENTAGE OF CONSTRUCTION ACTIVITY THAT IS NEW AND/OR RENOVATIVE AND THE PERCENTAGE OF CONSTRUCTION ACTIVITY THAT IS RESIDENTIAL AND/OR COMMERCIAL. __________________ % RENOVATIVE = 100% ___________________ % NEW + __________________ % COMMERCIAL = 100% ___________________ % RESIDENTIAL + 4. 5 YES NO DOES THIS ENTERPRISE WANT TO BECOME A PENNSYLVANIA LOTTERY RETAILER? American LegalNet, Inc. www.FormsWorkFlow.com PA-100 (03-09) DEPARTMENT USE ONLY ENTERPRISE NAME SECTION 8 – ESTABLISHMENT SALES INFORMATION 1. YES NO IS THIS ESTABLISHMENT SELLING TAXABLE PRODUCTS OR OFFERING TAXABLE SERVICES TO CONSUMERS FROM A LOCATION IN PENNSYLVANIA? IF YES, COMPLETE SECTION 18. 2. YES NO IS THIS ESTABLISHMENT SELLING CIGARETTES IN PENNSYLVANIA? IF YES, COMPLETE SECTIONS 18 AND 19. 3. LIST EACH COUNTY IN PENNSYLVANIA WHERE THIS ESTABLISHMENT IS CONDUCTING TAXABLE SALES ACTIVITY(IES). COUNTY COUNTY COUNTY COUNTY COUNTY COUNTY ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY. SECTION 9 – ESTABLISHMENT EMPLOYMENT INFORMATION PART 1 1. YES NO DOES THIS ESTABLISHMENT EMPLOY INDIVIDUALS WHO WORK IN PENNSYLVANIA? IF YES, INDICATE: a. DATE WAGES FIRST PAID (MM/DD/YYYY) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. DATE WAGES RESUMED FOLLOWING A BREAK IN EMPLOYMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c. TOTAL NUMBER OF EMPLOYEES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d. NUMBER OF EMPLOYEES PRIMARILY WORKING IN NEW BUILDING OR INFRASTRUCTURE . . . . . . . . . . . . . . . . e. NUMBER OF EMPLOYEES PRIMARILY WORKING IN REMODELING CONSTRUCTION . . . . . . . . . . . . . . . . . . . . . . f. ESTIMATED GROSS WAGES PER QUARTER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ g. NAME OF WORKERSʼ COMPENSATION INSURANCE COMPANY 1. 2. .00 POLICY NUMBER _________________________________ EFFECTIVE START DATE __________________ END DATE ___________________ ( ) AGENCY NAME ______________________________________________________ DAYTIME TELEPHONE NUMBER ______________________ MAILING ADDRESS _____________________________________ CITY/TOWN ______________________STATE _____ ZIP CODE + 4________ 3. IF THIS ENTERPRISE DOES NOT HAVE WORKERSʼ COMPENSATION INSURANCE, CHECK ONE: a. THIS ESTABLISHMENT EMPLOYS ONLY EXCLUDED WORKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . b. THIS ESTABLISHMENT HAS ZERO EMPLOYEES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c. THIS ESTABLISHMENT RECEIVED APPROVAL TO SELF-INSURE BY THE PA BUREAU OF WORKERSʼ COMPENSATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IF ITEM 3c. IS CHECKED, PROVIDE PA WORKERSʼ COMPENSATION BUREAU CODE 2. YES NO DOES THIS ESTABLISHMENT EMPLOY PA RESIDENTS WHO WORK OUTSIDE OF PENNSYLVANIA? IF YES, INDICATE: a. DATE WAGES FIRST PAID (MM/DD/YYYY) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. 3. YES DATE WAGES RESUMED FOLLOWING A BREAK IN EMPLOYMENT . . . . . . . . . . . . . . . . . . . . . . . . . c. ESTIMATED GROSS WAGES PER QUARTER. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ .00 NO DOES THIS ESTABLISHMENT PAY REMUNERATION FOR SERVICES TO PERSONS YOU DO NOT CONSIDER EMPLOYEES? IF YES, EXPLAIN THE SERVICES PERFORMED NO IS THIS REGISTRATION A RESULT OF A TAXABLE DISTRIBUTION FROM A BENEFIT TRUST, DEFERRED PAYMENT, OR RETIREMENT PLAN FOR PA RESIDENTS? PART 2 1. YES IF YES, INDICATE: a. b. DATE BENEFITS FIRST PAID (MM/DD/YYYY) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ESTIMATED BENEFITS PAID PER QUARTER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ .00 SECTION 10 – BULK SALE/TRANSFER INFORMATION IF ASSETS WERE ACQUIRED IN BULK FROM MORE THAN ONE ENTERPRISE, PHOTOCOPY THIS SECTION AND PROVIDE THE FOLLOWING INFORMATION ABOUT EACH SELLER/TRANSFEROR. 1. YES NO DID THE ENTERPRISE ACQUIRE 51% OR MORE OF ANY CLASS OF THE PA ASSETS OF ANOTHER ENTERPRISE? SEE THE CLASS OF ASSETS LISTED BELOW. 2. YES NO DID THE ENTERPRISE ACQUIRE 51% OR MORE OF THE TOTAL ASSETS OF ANOTHER ENTERPRISE? IF THE ANSWER TO EITHER QUESTION IS YES, PROVIDE THE FOLLOWING INFORMATION ABOUT THE SELLER/TRANSFEROR. 3. SELLER/TRANSFEROR NAME 4. FEDERAL EIN 5. SELLER/TRANSFEROR STREET ADDRESS 6. DATE ASSETS ACQUIRED CITY/TOWN STATE ZIP CODE + 4 7. ASSETS ACQUIRED: ACCOUNTS RECEIVABLE CONTRACTS CUSTOMERS/CLIENTS EQUIPMENT FIXTURES FURNITURE INVENTORY LEASES MACHINERY NAME AND/OR GOODWILL REAL ESTATE OTHER IMPORTANT: IF, IN ADDITION TO ACQUIRING ASSETS IN BULK, THE ENTERPRISE ALSO ACQUIRED ALL OR PART OF A PREDECESSOR'S BUSINESS, SECTION 14 MUST BE COMPLETED. IF THE ENTERPRISE IS ACQUIRING 51% OR MORE OF ANY CLASS OF PA ASSETS AND/OR 51% OF THE TOTAL ASSETS OF ANOTHER ENTERPRISE THE SELLER MUST OBTAIN A BULK SALE CLEARANCE CERTIFICATE. REFER TO INSTRUCTIONS ON PAGE 22. 6 American LegalNet, Inc. www.FormsWorkFlow.com PA-100 (03-09) DEPARTMENT USE ONLY ENTERPRISE NAME SECTION 11 – CORPORATION INFORMATION 1. DATE OF INCORPORATION 2. STATE OF INCORPORATION 5. IS THIS CORPORATION'S STOCK PUBLICLY TRADED? YES NO 3. CERTIFICATE OF AUTHORITY DATE (NON-PA CORP.) 4. COUNTRY OF INCORPORATION 6. CHECK THE APPROPRIATE BOX(ES) TO DESCRIBE THIS CORPORATION: CORPORATION: STOCK PROFESSIONAL NON-STOCK COOPERATIVE MANAGEMENT STATUTORY CLOSE 7. S CORPORATION: FEDERAL BANK: STATE MUTUAL THRIFT: FEDERAL STATE INSURANCE PA FEDERAL COMPANY: NON-PA IN ACCORDANCE WITH ACT NO.67 OF 2006, A CORPORATION WITH FEDERAL SUB-CHAPTER S STATUS IS CONSIDERED A PA S CORPORATION. IN ORDER NOT TO BE TAXED AS A PA S CORPORATION, REV-976 MUST BE FILED. THE FORM CAN BE ACCESSED AT WWW.REVENUE.STATE.PA.US, FORMS AND PUBLICATIONS, CORPORATION TAX. COMPLETING THIS FORM WILL NOT FULFILL THE REQUIREMENT TO REGISTER FOR CORPORATE TAXES. REGISTERING CORPORATIONS MUST CONTACT THE PA DEPARTMENT OF STATE TO SECURE CORPORATE NAME CLEARANCE AND REGISTER FOR CORPORATION TAX PURPOSES. CONTACT THE PA DEPARTMENT OF STATE AT (717) 7871057, OR VISIT www.paopenforbusiness.state.pa.us. SECTION 12 – REPORTING & PAYMENT METHODS 1. THE DEPARTMENT OF REVENUE REQUIRES THAT ANY ENTERPRISE MAKING PAYMENTS EQUAL TO OR GREATER THAN $20,000 REMIT PAYMENTS VIA ONE OF THE FOLLOWING ELECTRONIC METHODS: ELECTRONIC FUNDS TRANSFER (EFT); ELECTRONIC TAX INFORMATION AND DATA EXCHANGE SYSTEM (e-TIDES); TELEFILE SYSTEM OR CREDIT CARD. AN ENTERPRISE, REGARDLESS OF AMOUNT, IS ENCOURAGED TO REMIT TAX PAYMENTS ELECTRONICALLY. a. NO DOES THIS ENTERPRISE MEET THE DEPARTMENT OF REVENUEʼS REQUIREMENTS FOR ELECTRONIC PAYMENTS? b. 2. YES YES NO DOES THIS ENTERPRISE WANT TO PARTICIPATE IN THE DEPARTMENT OF REVENUEʼS ELECTRONIC PROGRAMS? NO IF THIS ENTERPRISE IS A NON-PROFIT ORGANIZATION THAT IS EXEMPT UNDER IRC 501(c)(3), OR POLITICAL SUB-DIVISIONS, IS IT INTERESTED IN RECEIVING INFORMATION ABOUT THE DEPARTMENT OF LABOR & INDUSTRYʼS OPTION OF FINANCING UC COSTS UNDER THE REIMBURSEMENT METHOD IN LIEU OF THE CONTRIBUTORY METHOD? FOR MORE DETAILS, REFER TO SECTION 12 INSTRUCTIONS. YES THE DEPARTMENT OF LABOR & INDUSTRY REQUIRES THAT ANY ENTERPRISE WITH 250 OR MORE WAGE ENTRIES PER QUARTERLY REPORT, FILE THE WAGE INFORMATION VIA MAGNETIC MEDIA. ANY MAGNETIC REPORTING FILE MUST BE SUBMITTED FOR COMPATIBILITY WITH THE DEPARTMENT OF LABOR & INDUSTRYʼS FORMAT. CONTACT THE MAGNETIC MEDIA REPORTING UNIT AT (717) 783-5802 FOR MORE INFORMATION. THE COMMONWEALTH STRONGLY RECOMMENDS THAT ENTERPRISES USE ELECTRONIC FILING AND PAYMENT OPTIONS FOR CERTAIN PENNSYLVANIA TAXES AND SERVICES. INFORMATION ABOUT INTERNET FILING OPTIONS CAN BE FOUND ON THE e-TIDES WEB SITE AT www.etides.state.pa.us. SECTION 13 – GOVERNMENT STRUCTURE 1. IS THE ENTERPRISE A: GOVERNMENT BODY GOVERNMENT OWNED ENTERPRISE GOVERNMENT & PRIVATE SECTOR OWNED ENTERPRISE DOMESTIC/USA FOREIGN/NON-USA MULTI-NATIONAL 2. IS THE GOVERNMENT: 3. IF DOMESTIC, IS THE GOVERNMENT: FEDERAL COUNTY BOROUGH STATE GOVERNOR'S JURISDICTION LOCAL: CITY SCHOOL DISTRICT STATE NON-GOVERNOR'S JURISDICTION TOWN OTHER TOWNSHIP 7 American LegalNet, Inc. www.FormsWorkFlow.com PA-100 (03-09) DEPARTMENT USE ONLY ENTERPRISE NAME SECTION 14 – PREDECESSOR/SUCCESSOR INFORMATION COMPLETE THIS SECTION IF THE REGISTERING ENTERPRISE IS WHOLLY OR PARTIALLY SUCCEEDING A PREDECESSOR. FOR ASSISTANCE, CONTACT THE NEAREST DEPARTMENT OF LABOR & INDUSTRY FIELD ACCOUNTING SERVICE OFFICE. IF THE ENTERPRISE HAS MORE THAN ONE PREDECESSOR, PHOTOCOPY THIS PAGE TO PROVIDE THE FOLLOWING INFORMATION ABOUT EACH. 1. PREDECESSOR LEGAL NAME 2. PREDECESSOR PA UC ACCOUNT NUMBER 3. PREDECESSOR TRADE NAME 4. PREDECESSOR FEDERAL EIN 5. PREDECESSOR STREET ADDRESS CITY/TOWN 6. SPECIFY HOW THE BUSINESS WAS ACQUIRED: CONSOLIDATION 7. GIFT STATE PURCHASE CHANGE IN LEGAL STRUCTURE IRC SEC. 338 ELECTION MERGER ZIP CODE + 4 OTHER (SPECIFY) ACQUISITION DATE 8. PERCENTAGE OF THE PREDECESSOR'S TOTAL BUSINESS (PA AND NON-PA) ACQUIRED % 9. PERCENTAGE OF THE PREDECESSOR'S PA BUSINESS ACQUIRED % IF LESS THAN 100%, PROVIDE THE NAME(S) AND ADDRESS(ES) OF THE ESTABLISHMENT(S) THAT CONDUCTED OPERATIONS IN PA OR EMPLOYED PA RESIDENTS. ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY. NAME OF ESTABLISHMENT(S) ADDRESS(ES) 10. WHAT WAS THE PREDECESSORʼS BUSINESS ACTIVITY IN THE PA BUSINESS THAT WAS ACQUIRED? 11. ASSETS ACQUIRED: ACCOUNTS RECEIVABLE CONTRACTS CUSTOMERS/CLIENTS EMPLOYEES EQUIPMENT FIXTURES FURNITURE INVENTORY LEASES MACHINERY NAME AND/OR GOODWILL REAL ESTATE OTHER (SPECIFY) 12. YES NO HAS THE PREDECESSOR CEASED PAYING WAGES IN PA? IF YES, ENTER THE DATE PA WAGES CEASED, IF KNOWN. 13. YES NO HAS THE PREDECESSOR CEASED OPERATIONS IN PA? IF YES, ENTER THE DATE PA OPERATIONS CEASED, IF KNOWN. IF NO, DESCRIBE THE PREDECESSOR'S PRESENT PA BUSINESS ACTIVITY, IF KNOWN. 14. AT THE TIME OF TRANSFER FROM THE PREDECESSOR ENTERPRISE TO THE REGISTERING ENTERPRISE: a. YES NO WERE ANY OF THE OWNERS, SHAREHOLDERS (5% OR GREATER), PARTNERS, OFFICERS, OR DIRECTORS OF THE PREDECESSOR OR OF ANY AFFILIATE, SUBSIDIARY OR PARENT CORPORATION OF THE PREDECESSOR ALSO OWNERS, SHAREHOLDERS (5% OR GREATER), PARTNERS, OFFICERS, OR DIRECTORS OF THE REGISTERING ENTERPRISE OR OF ANY AFFILIATE, SUBSIDIARY OR PARENT CORPORATION OF THE REGISTERING ENTERPRISE? b. YES NO WAS THE PREDECESSOR, OR ANY AFFILIATE, SUBSIDIARY OR PARENT CORPORATION OF THE PREDECESSOR, AN OWNER, SHAREHOLDER (5% OR GREATER), OR PARTNER IN THE REGISTERING ENTERPRISE? c. YES NO WAS THE REGISTERING ENTERPRISE, OR ANY AFFILIATE, SUBSIDIARY OR PARENT CORPORATION OF THE REGISTERING ENTERPRISE, AN OWNER, SHAREHOLDER (5% OR GREATER), OR PARTNER IN THE PREDECESSOR? IF THE ANSWER TO ANY OF THE QUESTIONS IN 14 IS YES, PROVIDE THE FOLLOWING INFORMATION. ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY. IDENTIFY THOSE PERSONS AND ENTITIES BY THEIR FULL NAME; DESCRIBE THEIR RELATIONSHIP TO THE PREDECESSOR AND ANY AFFILIATE, SUBSIDIARY AND PARENT CORPORATION OF THE PREDECESSOR; AND DESCRIBE THEIR RELATIONSHIP TO THE REGISTERING ENTERPRISE AND ANY AFFILIATE, SUBSIDIARY AND PARENT CORPORATION OF THE REGISTERING ENTERPRISE. THE REGISTERING ENTERPRISE MAY APPLY FOR A TRANSFER IN WHOLE OR IN PART OF THE PREDECESSOR'S UNEMPLOYMENT COMPENSATION (UC) EXPERIENCE RECORD AND RESERVE ACCOUNT BALANCE, IF THE REGISTERING ENTERPRISE IS CONTINUING ESSENTIALLY THE SAME BUSINESS ACTIVITY AS THE PREDECESSOR AND BOTH PROVIDED PA COVERED EMPLOYMENT. COMPLETE SECTION 15 AND, IF APPLICABLE, SECTION 16. NOTE: A REGISTERING ENTERPRISE MAY APPLY THE UC TAXABLE WAGES PAID BY A PREDECESSOR TOWARD THE REGISTERING ENTERPRISEʼS UC TAXABLE WAGE BASE FOR THE CALENDAR YEAR OF ACQUISITION WITHOUT TRANSFERRING THE PREDECESSOR'S EXPERIENCE RECORD AND RESERVE ACCOUNT BALANCE. 8 American LegalNet, Inc. www.FormsWorkFlow.com PA-100 (03-09) DEPARTMENT USE ONLY ENTERPRISE NAME SECTION 15 – APPLICATION FOR PA UC EXPERIENCE RECORD AND RESERVE ACCOUNT BALANCE OF PREDECESSOR A REGISTERING ENTERPRISE MAY APPLY THE UNEMPLOYMENT COMPENSATION (UC) TAXABLE WAGES PAID BY A PREDECESSOR TOWARD THE REGISTERING ENTERPRISEʼS UC TAXABLE WAGE BASE FOR THE CALENDAR YEAR OF ACQUISITION WITHOUT TRANSFERRING THE PREDECESSOR'S EXPERIENCE RECORD AND RESERVE ACCOUNT BALANCE. REFER TO THE INSTRUCTIONS TO DETERMINE IF IT IS ADVANTAGEOUS TO APPLY FOR A PREDECESSOR'S UC EXPERIENCE RECORD AND RESERVE ACCOUNT BALANCE. IMPORTANT: THIS APPLICATION CANNOT BE CONSIDERED UNLESS IT IS SIGNED BY AN AUTHORIZED SIGNATORY OF BOTH THE PREDECESSOR AND THE REGISTERING ENTERPRISE. THE TRANSFER IN WHOLE OR IN PART OF THE EXPERIENCE RECORD AND RESERVE ACCOUNT BALANCE IS BINDING AND IRREVOCABLE ONCE IT HAS BEEN APPROVED BY THE DEPARTMENT OF LABOR AND INDUSTRY. APPLICATION IS HEREBY MADE BY THE PREDECESSOR AND THE REGISTERING ENTERPRISE FOR A TRANSFER TO THE REGISTERING ENTERPRISE OF THE PENNSYLVANIA UNEMPLOYMENT COMPENSATION EXPERIENCE RECORD AND RESERVE ACCOUNT BALANCE OF THE PREDECESSOR WITH RESPECT TO THE TRANSFER. WE HEREBY CERTIFY THAT THE TRANSFER REFERENCED IN SECTION 14 HAS OCCURRED AS DESCRIBED THEREIN AND THAT THE REGISTERING ENTERPRISE IS CONTINUING ESSENTIALLY THE SAME BUSINESS ACTIVITY AS THE PREDECESSOR. WE ALSO HEREBY CERTIFY THAT THE TRANSFER REFERENCED IN SECTION 14 WAS NOT UNDERTAKEN PRIMARILY TO OBTAIN A LOWER UC TAX RATE, BUT HAD A LEGITIMATE BUSINESS PURPOSE UNRELATED TO UNEMPLOYMENT COMPENSATION TAXES. COMPLETE THIS SECTION ONLY IF YOU WANT TO APPLY FOR THE PREDECESSORʼS EXPERIENCE RECORD AND RESERVE ACCOUNT BALANCE. 1. PREDECESSOR NAME DATE AUTHORIZED SIGNATURE TYPE OR PRINT NAME TITLE 2. REGISTERING ENTERPRISE NAME DATE AUTHORIZED SIGNATURE TYPE OR PRINT NAME TITLE SECTION 16 - UNEMPLOYMENT COMPENSATION PARTIAL TRANSFER INFORMATION COMPLETE THIS SECTION IF THE REGISTERING ENTERPRISE ACQUIRED ONLY PART OF THE PREDECESSOR'S PENNSYLVANIA (PA) BUSINESS AND IS MAKING APPLICATION FOR THE TRANSFER OF A PORTION OF THE PREDECESSOR'S EXPERIENCE RECORD AND RESERVE ACCOUNT BALANCE. COMPLETE REPLACEMENT UC-2A FOR PARTIAL TRANSFER (FORM UC-252). THE PREDECESSOR'S PA PAYROLL RECORDS FOR THE TWO YEARS PRIOR TO THE QUARTER OF THE TRANSFER AND/OR ACQUISITION MUST REMAIN AVAILABLE TO THE REGISTERING ENTERPRISE TO ENABLE THE REGISTERING ENTERPRISE TO PROVIDE REQUIRED INFORMATION REGARDING SEPARATED AND/OR TRANSFERRED EMPLOYEES. UNEMPLOYMENT COMPENSATION (UC) TAXABLE WAGES ARE THOSE WAGES THAT DO NOT EXCEED THE UC TAXABLE WAGE BASE APPLICABLE TO A GIVEN CALENDAR YEAR. 1. DATE WAGES FIRST PAID BY PREDECESSOR OR PRE-PREDECESSOR(S) IN THE PART OF THE PA BUSINESS OR WORKFORCE TRANSFERRED (ACQUIRED) FOR WHICH CONTRIBUTIONS WERE PAID UNDER THE PROVISIONS OF THE PA UC LAW. DATE:________________________________ 2. ENTER THE NUMBER OF EMPLOYEES WHO WORKED IN THE PART OF THE BUSINESS OR WORKFORCE THAT WAS TRANSFERRED FOR EACH QUARTER IN THE TABLE BELOW. IF NO EMPLOYMENT WAS GIVEN IN ANY QUARTER, ENTER “0”. YEAR________ YEAR________ QUARTERS 1 2 3 YEAR________ QUARTERS 4 1 2 3 YEAR________ QUARTERS 4 1 2 3 QUARTERS 4 1 2 3 YEAR________ OF TRANSFER QUARTERS YEAR________ QUARTERS 4 1 2 3 4 1 2 3 4 3. ENTER THE NUMBER OF EMPLOYEES WHO WORKED IN THE ENTIRE BUSINESS FOR EACH QUARTER IN THE TABLE BELOW. IF NO EMPLOYMENT WAS GIVEN IN ANY QUARTER, ENTER “0”. YEAR________ YEAR________ QUARTERS 1 2 3 YEAR________ QUARTERS 4 1 2 3 YEAR________ QUARTERS 4 1 2 3 QUARTERS 4 1 2 3 YEAR________ OF TRANSFER QUARTERS YEAR________ QUARTERS 4 1 2 3 4 1 2 3 4 4. IF THE PART OF THE BUSINESS OR WORKFORCE THAT WAS TRANSFERRED WAS IN EXISTENCE FOR LESS THAN THREE FULL CALENDAR YEARS PRIOR TO THE YEAR OF TRANSFER, ENTER THE FOLLOWING: A. TOTAL NUMBER OF EMPLOYEES WHO EARNED TAXABLE WAGES IN THE PART OF THE BUSINESS OR WORKFORCE THAT WAS TRANSFERRED DURING THE PERIOD FROM THE FIRST DAY OF THE QUARTER OF TRANSFER TO THE DATE OF TRANSFER . B. TOTAL NUMBER OF EMPLOYEES WHO EARNED TAXABLE WAGES IN THE ENTIRE BUSINESS DURING THE PERIOD FROM THE FIRST DAY OF THE QUARTER OF TRANSFER TO THE DATE OF TRANSFER . 5. PREDECESSOR'S ENTIRE PA UC TAXABLE PAYROLL, FOR THE PERIOD FROM THE FIRST DAY OF THE QUARTER OF TRANSFER TO THE DATE OF TRANSFER ____________________________ . 9 American LegalNet, Inc. www.FormsWorkFlow.com PA-100 (03-09) DEPARTMENT USE ONLY ENTERPRISE NAME SECTION 17 – MULTIPLE ESTABLISHMENT INFORMATION COMPLETE THIS SECTION FOR EACH ADDITIONAL ESTABLISHMENT CONDUCTING BUSINESS IN PA OR EMPLOYING PA RESIDENTS. PHOTOCOPY THIS SECTION AS NECESSARY. . PART 1 ESTABLISHMENT INFORMATION 1. ESTABLISHMENT NAME (doing business as) 2. DATE OF FIRST OPERATIONS 3. TELEPHONE NUMBER ( 4. STREET ADDRESS CITY/TOWN 5. PA SCHOOL DISTRICT PART 2 COUNTY STATE ) ZIP CODE + 4 6. PA MUNICIPALITY ESTABLISHMENT BUSINESS ACTIVITY INFORMATION REFER TO THE INSTRUCTIONS ON PAGES 20 & 21 TO COMPLETE THIS SECTION. 1. ENTER THE PERCENTAGE EACH PA BUSINESS ACTIVITY REPRESENTS OF THE TOTAL RECEIPTS OR REVENUES AT THIS ESTABLISHMENT. LIST PRODUCTS OR SERVICES ASSOCIATED WITH EACH BUSINESS ACTIVITY AND THE PERCENTAGE REPRESENTING OF THE TOTAL RECEIPTS OR REVENUES. PA BUSINESS ACTIVITY % PRODUCTS OR SERVICES % ADDITIONAL PRODUCTS OR SERVICES % Accommodation & Food Services Agriculture, Forestry, Fishing, & Hunting Art, Entertainment, & Recreation Services Communications/Information Construction (must complete question 3) Domestics (Private Households) Educational Services Finance Health Care Services Insurance Management, Support & Remediation Services Manufacturing Mining, Quarrying, & Oil/Gas Extraction Other Services Professional, Scientific, & Technical Services Public Administration Real Estate Retail Trade Sanitary Service Social Assistance Services Transportation Utilities Warehousing Wholesale Trade TOTAL 100% 2. ENTER THE PERCENTAGE THAT THIS ESTABLISHMENTʼS RECEIPTS OR REVENUES REPRESENT OF THE TOTAL PA RECEIPTS OR REVENUES OF THE ENTERPRISE.________ % 3. ESTABLISHMENTS ENGAGED IN CONSTRUCTION MUST ENTER THE PERCENTAGE OF CONSTRUCTION ACTIVITY THAT IS NEW AND/OR RENOVATIVE AND THE PERCENTAGE OF CONSTRUCTION ACTIVITY THAT IS RESIDENTIAL AND/OR COMMERCIAL. ___________________ % NEW + __________________ % RENOVATIVE = 100% ___________________ % RESIDENTIAL + __________________ % COMMERCIAL = 100% 10 American LegalNet, Inc. www.FormsWorkFlow.com PA-100 (03-09) DEPARTMENT USE ONLY ENTERPRISE NAME PART 3 ESTABLISHMENT SALES INFORMATION 1. YES NO IS THIS ESTABLISHMENT SELLING TAXABLE PRODUCTS OR OFFERING TAXABLE SERVICES TO CONSUMERS FROM A LOCATION IN PENNSYLVANIA? IF YES, COMPLETE SECTION 18. 2. YES NO IS THIS ESTABLISHMENT SELLING CIGARETTES IN PENNSYLVANIA? IF YES, COMPLETE SECTIONS 18 AND 19. 3. LIST EACH COUNTY IN PENNSYLVANIA WHERE THIS ESTABLISHMENT IS CONDUCTING TAXABLE SALES ACTIVITY(IES). COUNTY COUNTY COUNTY COUNTY COUNTY COUNTY ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY. PART 4a 1. ESTABLISHMENT EMPLOYMENT INFORMATION YES NO DOES THIS ESTABLISHMENT EMPLOY INDIVIDUALS WHO WORK IN PENNSYLVANIA? IF YES, INDICATE: a. NUMBER OF EMPLOYEES PRIMARILY WORKING IN NEW BUILDING OR INFRASTRUCTURE . . . e. NUMBER OF EMPLOYEES PRIMARILY WORKING IN REMODELING CONSTRUCTION . . . . . . . . . f. NO TOTAL NUMBER OF EMPLOYEES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . d. YES DATE WAGES RESUMED FOLLOWING A BREAK IN EMPLOYMENT . . . . . . . . . . . . . . . . . . . . . . . . . c. 2. DATE WAGES FIRST PAID (MM/DD/YYYY) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. ESTIMATED GROSS WAGES PER QUARTER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ DOES THIS ESTABLISHMENT EMPLOY PA RESIDENTS WHO WORK OUTSIDE OF PENNSYLVANIA? IF YES, INDICATE: a. NO DATE WAGES RESUMED FOLLOWING A BREAK IN EMPLOYMENT . . . . . . . . . . . . . . . . . . . . . . . . . c. YES DATE WAGES FIRST PAID (MM/DD/YYYY) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. 3. .00 ESTIMATED GROSS WAGES PER QUARTER. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ .00 DOES THIS ESTABLISHMENT PAY REMUNERATION FOR SERVICES TO PERSONS YOU DO NOT CONSIDER EMPLOYEES? IF YES, EXPLAIN THE SERVICES PERFORMED PART 4b 1. YES NO IS THIS REGISTRATION A RESULT OF A TAXABLE DISTRIBUTION FROM A BENEFIT TRUST, DEFERRED PAYMENT OR RETIREMENT PLAN FOR PA RESIDENTS? IF YES, INDICATE: a. DATE BENEFITS FIRST PAID (MM/DD/YYYY) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. .00 ESTIMATED BENEFITS PAID PER QUARTER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ SECTION 6A – ADDITIONAL OWNERS, PARTNERS, SHAREHOLDERS, OFFICERS, AND RESPONSIBLE PARTY INFORMATION PROVIDE THE FOLLOWING FOR ALL INDIVIDUAL AND/OR ENTERPRISE OWNERS, PARTNERS, SHAREHOLDERS, OFFICERS, AND RESPONSIBLE PARTIES. IF STOCK IS PUBLICLY TRADED, PROVIDE THE FOLLOWING FOR ANY SHAREHOLDER WITH AN EQUITY POSITION OF 5% OR MORE. PHOTOCOPY IF ADDITIONAL SPACE IS NEEDED. 1. NAME 5. OWNER OFFICER PARTNER SHAREHOLDER RESPONSIBLE PARTY 10. HOME ADDRESS (street) 2. SOCIAL SECURITY NUMBER 6. TITLE 3. DATE OF BIRTH * 7. EFFECTIVE DATE OF TITLE 4. FEDERAL EIN 8. PERCENTAGE OF OWNERSHIP 9. EFFECTIVE DATE OF OWNERSHIP % CITY/TOWN 11. THIS PERSON IS RESPONSIBLE TO REMIT/MAINTAIN: SALES TAX COUNTY STATE EMPLOYER WITHHOLDING TAX ZIP CODE + 4 MOTOR FUEL TAXES WORKERSʼ COMPENSATION COVERAGE 1. NAME 5. OWNER OFFICER PARTNER SHAREHOLDER RESPONSIBLE PARTY 2. SOCIAL SECURITY NUMBER 6. TITLE 10. HOME ADDRESS (street) 11. THIS PERSON IS RESPONSIBLE TO REMIT/MAINTAIN: 3. DATE OF BIRTH * 7. EFFECTIVE DATE OF TITLE 4. FEDERAL EIN 8. PERCENTAGE OF OWNERSHIP 9. EFFECTIVE DATE OF OWNERSHIP % CITY/TOWN SALES TAX COUNTY EMPLOYER WITHHOLDING TAX STATE ZIP CODE + 4 MOTOR FUEL TAXES WORKERSʼ COMPENSATION COVERAGE * DATE OF BIRTH REQUIRED ONLY IF APPLYING FOR A CIGARETTE WHOLESALE DEALERʼS LICENSE, A SMALL GAMES OF CHANCE DISTRIBUTOR LICENSE, OR A SMALL GAMES OF CHANCE MANUFACTURER CERTIFICATE. 11 American LegalNet, Inc. www.FormsWorkFlow.com PA-100 (03-09) DEPARTMENT USE ONLY ENTERPRISE NAME SECTION 18 – SALES USE AND HOTEL OCCUPANCY TAX LICENSE, PUBLIC TRANSPORTATION ASSISTANCE TAX LICENSE, VEHICLE RENTAL TAX, TRANSIENT VENDOR CERTIFICATE, PROMOTER LICENSE, OR WHOLESALER CERTIFICATE PART 1 SALES USE AND HOTEL OCCUPANCY TAX, PUBLIC TRANSPORTATION ASSISTANCE TAX, VEHICLE RENTAL TAX, OR WHOLESALER CERTIFICATE ENTERPRISES APPLYING FOR A SALES, USE AND HOTEL OCCUPANCY TAX LICENSE, PUBLIC TRANSPORTATION ASSISTANCE TAX LICENSE, VEHICLE RENTAL TAX, AND/OR WHOLESALER CERTIFICATE. COMPLETE PART 1. SALES TAX COLLECTED MUST BE SEGREGATED FROM OTHER FUNDS AND MUST REMAIN IN THE COMMONWEALTH OF PENNSYLVANIA UNTIL REMITTED TO THE DEPARTMENT OF REVENUE. IF THE ENTERPRISE IS: SELLING TAXABLE PRODUCTS OR SERVICES TO CONSUMERS IN PENNSYLVANIA, ENTER DATE OF FIRST TAXABLE SALE PURCHASING TAXABLE PRODUCTS OR SERVICES FOR ITS OWN USE IN PENNSYLVANIA AND INCURRING NO SALES TAX, ENTER DATE OF FIRST PURCHASE SELLING NEW TIRES TO CONSUMERS IN PENNSYLVANIA, ENTER DATE OF FIRST SALE LEASING OR RENTING MOTOR VEHICLES, ENTER DATE OF FIRST LEASE OR RENTAL RENTING FIVE OR MORE MOTOR VEHICLES, ENTER DATE OF FIRST RENTAL CONDUCTING RETAIL SALES IN PENNSYLVANIA AND NOT MAINTAINING A PERMANENT LOCATION IN PA, ENTER DATE OF FIRST TAXABLE SALE (COMPLETE PART 2) ACTIVELY PROMOTING SHOWS IN PENNSYLVANIA WHERE TAXABLE PRODUCTS WILL BE OFFERED FOR RETAIL SALE, ENTER DATE OF FIRST SHOW (COMPLETE PART 3) ENGAGED SOLELY IN THE SALE OF TANGIBLE PERSONAL PROPERTY AND/OR SERVICES FOR RESALE OR RENTAL, ENTER DATE OF FIRST PURCHASE PART 2 TRANSIENT VENDOR CERTIFICATE IF THE ENTERPRISE PARTICIPATES IN ANY SHOWS OTHER THAN THOSE LISTED, PROVIDE THE NAME(S) OF THE SHOW(S) AND INFORMATION ABOUT THE SHOW(S) TO THE DEPARTMENT OF REVENUE AT LEAST 10 DAYS PRIOR TO THE SHOW. PROVIDE THE FOLLOWING INFORMATION FOR EACH SHOW: 1. PROMOTER NUMBER 2. SHOW NAME 3. COUNTY 4. SHOW ADDRESS (STREET, CITY, STATE, ZIP) 5. START DATE 1. PROMOTER NUMBER 3. COUNTY 2. SHOW NAME 4. SHOW ADDRESS (STREET, CITY, STATE, ZIP) 6. END DATE 5. START DATE 6. END DATE 3. START DATE 4. END DATE ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY. PART 3 PROMOTER LICENSE PROVIDE THE FOLLOWING INFORMATION FOR EACH SHOW: 1. SHOW NAME 2. TYPE OF SHOW 5. SHOW ADDRESS (STREET, CITY, STATE, ZIP) 1. SHOW NAME 5. SHOW ADDRESS (STREET, CITY, STATE, ZIP) 6. COUNTY 2. TYPE OF SHOW 7. NBR OF VENDORS 3. START DATE 6. COUNTY 4. END DATE 7. NBR OF VENDORS ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY. 12 American LegalNet, Inc. www.FormsWorkFlow.com PA-100 (03-09) DEPARTMENT USE ONLY ENTERPRISE NAME SECTION 19 – CIGARETTE DEALER’S LICENSE PART 1 LICENSE TYPE CHECK THE APPROPRIATE BOX(ES) TO INDICATE LICENSE TYPE REQUESTED. A SEPARATE LICENSE MUST BE OBTAINED FOR EACH ESTABLISHMENT THAT SELLS CIGARETTES (CSA, WHOLESALE, RETAIL, AND/OR VENDING). A SEPARATE DECAL MUST BE PURCHASED FOR EACH VENDING MACHINE LOCATION. A CHECK OR MONEY ORDER MUST BE SUBMITTED WITH THIS APPLICATION. LICENSE TYPE NUMBER FEE AMOUNT REMITTED RETAIL OVER-THE-COUNTER _____________________ @ $ 25 EACH LOCATION $ RETAIL OVER-THE-COUNTER ITINERANT _____________________ @ $ 25 EACH LOCATION $ VENDING MACHINE (ATTACH A LIST OF LOCATIONS) _____________________ @ $ 25 EACH DECAL $ WHOLESALER _____________________ @ $ 500 EACH LICENSE $ CIGARETTE STAMPING AGENT AND WHOLESALER _____________________ @ $ 1,500 EACH LICENSE $ TOTAL AMOUNT REMITTED $ MAKE CHECKS PAYABLE TO PA DEPARTMENT OF REVENUE PART 2 CIGARETTE WHOLESALER THE APPLICANT HAS COMPLIED WITH ARTICLE II-A OF THE CIGARETTE SALES AND LICENSING ACT. IN ACCORDANCE WITH THE ACT, UNDER PENALTY OF PERJURY, ADHERES TO THE STATE PRESUMPTIVE MINIMUM PRICES. LIST CIGARETTE STORAGE LOCATION(S) (PO BOXES ARE NOT ACCEPTABLE). 1. STREET ADDRESS CITY/TOWN 2. YES COUNTY NO STATE ZIP CODE + 4 HAS ANY OWNER, PARTNER, OFFICER, DIRECTOR, OR MAJOR STOCKHOLDER BEEN CONVICTED OF ANY VIOLATION OF THE PENNSYLVANIA CIGARETTE TAX ACT OR ANY MISDEMEANOR OR FELONY? IF YES, LIST ALL CONVICTIONS WITHIN THE PREVIOUS 10 YEAR PERIOD. ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY. PART 3 1. YES CIGARETTE STAMPING AGENT NO DOES THE ENTERPRISE PURCHASE OR SELL ANY CIGARETTES WHICH ARE NOT PA STAMPED? IF YES, LIST STATES: 13 American LegalNet, Inc. www.FormsWorkFlow.com PA-100 (03-09) DEPARTMENT USE ONLY ENTERPRISE NAME SECTION 20 – SMALL GAMES OF CHANCE LICENSE/CERTIFICATE PART 1 DISTRIBUTOR AND/OR MANUFACTURER TO BE COMPLETED BY ALL APPLICANTS (DISTRIBUTOR AND/OR MANUFACTURER) APPLICANTS MUST SUBMIT A COPY OF THE CERTIFICATE OF INCORPORATION, ARTICLES OF INCORPORATION, CERTIFICATE OF AUTHORITY (NON-PA CORPORATIONS), BYLAWS, CONSTITUTION, OR FICTITIOUS NAME REGISTRATION. APPLICANTS FOR A MANUFACTURER CERTIFICATE MUST SUBMIT A COPY OF THE COMPANY LOGO(S). 1. CHECK APPROPRIATE BOX(ES) TO INDICATE TYPE OF LICENSE/CERTIFICATE REQUESTED LICENSE/CERTIFICATE TYPE FEE AMOUNT REMITTED DISTRIBUTOR LICENSE $ 1,000 $ MANUFACTURER REGISTRATION CERTIFICATE $ 2,000 $ REPLACEMENT LICENSE $ 0100 $ REPLACEMENT CERTIFICATE $ 0100 $ $00010 $ NUMBER OF BACKGROUND INVESTIGATIONS FOR OWNERS/OFFICERS, ETC. _____________ @ TOTAL AMOUNT REMITTED $ MAKE CHECKS PAYABLE TO PA DEPARTMENT OF REVENUE IF THE DEPARTMENT DENIES AN APPLICATION, A $100 APPLICATION PROCESSING FEE SHALL BE RETAINED BY THE DEPARTMENT. NO PART OF THE REGISTRATION OR LICENSE FEE SHALL BE SUBJECT TO PRORATION. NO INVESTIGATION FEE SHALL BE REFUNDED. 2. DISTRIBUTORS AND MANUFACTURERS - PROVIDE THE FOLLOWING INFORMATION FOR THE COMMONWEALTH OF PA RESIDENT DESIGNEE. THE INDIVIDUAL MUST HAVE PHYSICAL LOCATION WITHIN PA. NAME HOME ADDRESS (STREET) CITY/TOWN STATE ZIP CODE + 4 TELEPHONE NBR. ( 3. ) DISTRIBUTORS AND MANUFACTURERS - PROVIDE THE FOLLOWING INFORMATION FOR ALL INDIVIDUALS RESPONSIBLE FOR TAKING ORDERS AND MAKING SALES OF SMALL GAMES OF CHANCE MERCHANDISE. IF AN INDIVIDUAL RESIDES IN PENNSYLVANIA, INDICATE IF COMMISSION OR NONCOMMISSION. NAME TITLE SELLS FOR DISTRIBUTOR COMMISSION SELLS FOR MANUFACTURER HOME ADDRESS (STREET) CITY/TOWN NAME TITLE HOME ADDRESS (STREET) STATE CITY/TOWN ZIP CODE + 4 NONCOMMISSION TELEPHONE NBR. ( SELLS FOR DISTRIBUTOR SELLS FOR MANUFACTURER STATE ) COMMISSION ZIP CODE + 4 NONCOMMISSION TELEPHONE NBR. ( ) ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY MANUFACTURERS ONLY MUST SUBMIT A CATALOG OF THE SMALL GAMES CHECKED BELOW. IF CATALOG IS UNAVAILABLE, PROVIDE NAME OF GAME(S) AND FORM NUMBER(S), NUMBER OF TICKETS PER DEAL, HIGHEST INDIVIDUAL PRIZE VALUE, AND PERCENTAGE OF PAYOUT. 4. CHECK THE APPROPRIATE BOX(ES) TO INDICATE THE TYPES OF SMALL GAMES DISTRIBUTED OR MANUFACTURED. DAILY DRAWINGS PART 2 WEEKLY DRAWINGS PULL-TABS PUNCHBOARDS RAFFLES DISPENSING MACHINES DISTRIBUTOR LIST ALL SMALL GAMES OF CHANCE MANUFACTURERS WITH WHOM THE DISTRIBUTOR DOES BUSINESS. MANUFACTURERʼS LEGAL NAME MANUFACTURERʼS CERTIFICATE NUMBER STREET ADDRESS MANUFACTURERʼS LEGAL NAME STREET ADDRESS MCITY/TOWN ( STATE MANUFACTURERʼS CERTIFICATE NUMBER MCITY/TOWN TELEPHONE NUMBER TELEPHONE NUMBER ( STATE ) ZIP CODE +4 ) ZIP CODE +4 ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY 14 American LegalNet, Inc. www.FormsWorkFlow.com SMALL GAMES OF CHANCE CERTIFICATION PART 3 MUST BE COMPLETED BY ALL SMALL GAMES OF CHANCE APPLICANTS. I CERTIFY THAT THE FOLLOWING TAX STATEMENTS ARE TRUE AND CORRECT: ALL PA STATE TAX REPORTS AND RETURNS HAVE BEEN FILED ALL PA STATE TAXES HAVE BEEN PAID ANY PA STATE TAXES OWED ARE SUBJECT TO TIMELY ADMINISTRATIVE OR JUDICIAL APPEAL; OR ANY DELINQUENT PA TAXES ARE SUBJECT TO DULY APPROVED DEFERRED PAYMENT PLAN (COPY ENCLOSED). I CERTIFY THAT NO OWNER, PARTNER, OFFICER, DIRECTOR, OR OTHER PERSON IN A SUPERVISORY OR MANAGEMENT POSITION, OR EMPLOYEE ELIGIBLE TO MAKE SALES ON BEHALF OF THIS BUSINESS: HAS BEEN CONVICTED OF A FELONY IN A STATE OR FEDERAL COURT WITHIN THE PAST FIVE YEARS HAS BEEN CONVICTED WITHIN TEN YEARS OF THE DATE OF APPLICATION IN A STATE OR FEDERAL COURT OF A VIOLATION OF THE BINGO LAW OR OF THE LOCAL OPTION SMALL GAMES OF CHANCE ACT, OR A GAMBLING-RELATED OFFENSE UNDER TITLE 18 OF THE PENNSYLVANIA CONSOLIDATED STATUTES OR OTHER COMPARABLE STATE OR FEDERAL LAW HAS NOT BEEN REJECTED IN ANY STATE FOR A DISTRIBUTOR LICENSE OR MANUFACTURER REGISTRATION CERTIFICATE, OR EQUIVALENT THERETO. I DECLARE THAT I HAVE EXAMINED THIS APPLICATION, INCLUDING ALL ACCOMPANYING STATEMENTS, AND TO THE BEST OF MY KNOWLEDGE AND BELIEF IT IS TRUE, CORRECT, AND COMPLETE. NOTARY AUTHORIZATION SWORN AND SUBSCRIBED TO BEFORE ME THIS _____________________ DAY OF _________________ , 20____ SIGNATURE OF AN OWNER, PARTNER, OFFICER, OR DIRECTOR PRINT NAME NOTARY PUBLIC SOCIAL SECURITY NUMBER DATE MY COMMISSION EXPIRES TITLE ( ) TELEPHONE NUMBER NOTARY SEAL 15 CORPORATE SEAL American LegalNet, Inc. www.FormsWorkFlow.com PA-100 (03-09) DEPARTMENT USE ONLY ENTERPRISE NAME SECTION 21 – MOTOR CARRIER REGISTRATION & DECAL/MOTOR FUELS LICENSE & PERMIT VEHICLE OPERATIONS PART 1 A DECAL IS REQUIRED IF AN ENTERPRISE IS OPERATING A QUALIFIED MOTOR VEHICLE, SEE PAGE 25, PART 1 - VEHICLE OPERATIONS. CHECK THE APPROPRIATE BOX(ES) TO DESCRIBE THE ENTERPRISE OPERATIONS: COMMON CARRIER CONTRACT CARRIER FOR HIRE CARRIER PRIVATE CARRIER US DOT NUMBER LP GAS CNG/LNG INDICATE THE FUEL TYPES FOR PENNSYLVANIA BASED QUALIFIED MOTOR VEHICLES: DIESEL GASOLINE ETHANOL/GASOHOL . YES NO HAVE YOU EVER BEEN ISSUED AN INTERNATIONAL FUEL TAX AGREEMENT (IFTA) CREDENTIAL FROM ANOTHER JURISDICTION(S)? . YES NO IF YES, IS THE LICENSE CURRENTLY SUSPENDED OR REVOKED? MOTOR CARRIER ROAD TAX/IFTA VEHICLE DECAL REQUESTS COMPLETE THE FOLLOWING FOR EACH QUALIFIED MOTOR VEHICLE YOU INTEND TO OPERATE IN PENNSYLVANIA DURING THE ENSUING CALENDAR YEAR: NOTE: DECALS ARE $5.00 PER SET OF TWO. 1. IFTA DECALS (NUMBER OF VEHICLES THAT TRAVEL IN PA AND OUT OF STATE) 2. NON-IFTA DECALS (NUMBER OF VEHICLES THAT TRAVEL IN PA EXCLUSIVELY) 3. TOTAL DECALS REQUESTED (ADD LINES 1 AND 2) 4. TOTAL AMOUNT DUE (MULTIPLY LINE 3 BY $5) $ REMITTANCE SUBMITTED: 5. AUTHORIZED ADJUSTMENT (ATTACH ORIGINAL CREDIT NOTICE) $ 6. CHECK OR MONEY ORDER AMOUNT $ MAKE CHECKS PAYABLE TO PA DEPARTMENT OF REVENUE CHECK THE APPROPRIATE BOX(ES) TO INDICATE THE JURISDICTION(S) WHERE: COLUMN A – QUALIFIED MOTOR VEHICLES ARE OPERATED COLUMN B – BULK STORAGE OF DIESEL FUEL IS MAINTAINED A B C D A B AK AL AR AZ CA CO CT DC DE FL GA HI IA A B A B ID – IL – IN – KS – KY – LA – MA – MD – ME – MI – MN – MO – MS – A B AB – ALBERTA BC – BRITISH COLUMBIA MB – MANITOBA PART 2 C D – ALASKA – ALABAMA – ARKANSAS – ARIZONA – CALIFORNIA – COLORADO – CONNECTICUT – DIST. OF COLUMBIA – DELAWARE – FLORIDA – GEORGIA – HAWAII – IOWA C D COLUMN C – BULK STORAGE FOR GASOLINE IS MAINTAINED COLUMN D – BULK STORAGE OF ANY OTHER MOTOR FUEL IS MAINTAINED C D IDAHO ILLINOIS INDIANA KANSAS KENTUCKY LOUISIANA MASSACHUSETTS MARYLAND MAINE MICHIGAN MINNESOTA MISSOURI MISSISSIPPI C D A B NB – NEW BRUNSWICK NF – NEWFOUNDLAND NS – NOVA SCOTIA A B MT – NC – ND – NE – NH – NJ – NM – NV – NY – OH – OK – OR – PA – C D MONTANA NORTH CAROLINA NORTH DAKOTA NEBRASKA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEVADA NEW YORK OHIO OKLAHOMA OREGON PENNSYLVANIA C D RI – SC – SD – TN – TX – UT – VA – VT – WA – WI – WV – WY – A B NT – N W TERRITORY ON – ONTARIO PE – PRINCE EDWARD IS. RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VIRGINIA VERMONT WASHINGTON WISCONSIN WEST VIRGINIA WYOMING C D PQ – QUEBEC SK – SASKATCHEWAN YT - YUKON TERRITORY FUELS TO REQUEST A LIQUID FUELS AND FUELS TAX PERMIT APPLICATION (REV-1338), CONTACT THE BUREAU OF MOTOR FUEL TAXES AT 1-800-482-4382 OR AT WWW.REVENUE.STATE.PA.US, FORMS AND PUBLICATIONS, MOTOR FUEL TAX. 16 American LegalNet, Inc. www.FormsWorkFlow.com PA-100 (03-09) DEPARTMENT USE ONLY ENTERPRISE NAME SECTION 22 – SALES TAX EXEMPT STATUS FOR CHARITABLE AND RELIGIOUS ORGANIZATIONS PART 1 ACT 55 OF 1997, KNOWN AS THE INSTITUTIONS OF PURELY PUBLIC CHARITY ACT, WAS SIGNED INTO LAW ON NOVEMBER 26, 1997. THIS LAW HAS CODIFIED THE REQUIREMENTS AN INSTITUTION MUST MEET IN ORDER TO QUALIFY FOR EXEMPTION, OUTLINING FIVE CRITERIA THAT MUST BE MET. EACH INSTITUTION MUST: (1) ADVANCE A CHARITABLE PURPOSE; (2) DONATE OR RENDER GRATUITOUSLY A SUBSTANTIAL PORTION OF ITS SERVICES; (3) BENEFIT A SUBSTANTIAL AND INDEFINITE CLASS OF PERSONS WHO ARE LEGITIMATE SUBJECTS OF CHARITY; (4) RELIEVE THE GOVERNMENT OF SOME BURDEN; (5) OPERATE ENTIRELY FREE FROM PRIVATE PROFIT MOTIVE. ORGANIZATIONS OF THE FOLLOWING TYPE DO NOT QUALIFY FOR EXEMPTION STATUS: AN ASSOCIATION OF EMPLOYEES, THE MEMBERSHIP OF WHICH IS LIMITED TO THE EMPLOYEES OF A DESIGNATED ENTERPRISE A LABOR ORGANIZATION AN AGRICULTURAL OR HORTICULTURAL ORGANIZATION A BUSINESS LEAGUE, CHAMBER OF COMMERCE, REAL ESTATE BOARD, BOARD OF TRADE, OR PROFESSIONAL SPORT LEAGUE A CLUB ORGANIZED FOR PLEASURE OR RECREATION A FRATERNAL BENEFICIARY SOCIETY, ORDER, OR ASSOCIATION TO APPLY OR RENEW A SALES TAX EXEMPTION STATUS, A REV-72 APPLICATION MUST BE COMPLETED AND SUBMITTED ALONG WITH THE REQUIRED DOCUMENTATION. THE APPLICATION CAN BE OBTAINED BY COMPLETING THE FORM BELOW; TELEPHONE THE TOLL FREE FACT & INFORMATION LINE AT 1-888-PATAXES (1-888-728-2937) OR CONTACT TAXPAYER SERVICE & INFORMATION CENTER AT (717) 787-1064; TT# ONLY 1-800-447-3020 (SERVICE FOR TAXPAYERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS) OR WWW.REVENUE.STATE.PA.US, FORMS & PUBLICATIONS, BUSINESS TAXES. SPECIFIC QUESTIONS REGARDING THE FORM CONTACT (717) 783-5473. IF THE CHARITABLE AND RELIGIOUS ORGANIZATION CONDUCTS SALES ACTIVITIES AND IS NOT REGISTERED FOR COLLECTION OF THE PA SALES TAX, REFER TO SECTION 18 OF THIS BOOKLET. ¡ PART 2 REQUEST FOR SALES TAX EXEMPT STATUS APPLICATION NAME MAILING ADDRESS CITY/TOWN STATE ZIP CODE + 4 TO REQUEST SALES TAX EXEMPT STATUS APPLICATION COMPLETE THIS FORM AND RETURN TO: PA DEPARTMENT OF REVENUE BUREAU OF BUSINESS TRUST FUND TAXES PO BOX 280909 HARRISBURG, PA 17128-0909 17 American LegalNet, Inc. www.FormsWorkFlow.com PA-100 (03-09) SECTION 1 – REASON FOR THIS REGISTRATION IF THE BUSINESS STRUCTURE IS: USE THE: An enterprise may select more than one reason for registration. SOLE PROPRIETORSHIP INDIVIDUAL OWNERʼS NAME. 1. CORPORATION NAME AS SHOWN IN THE ARTICLES OF INCORPORATION. PARTNERSHIP NAME AS SHOWN IN THE PARTNERSHIP AGREEMENT. ASSOCIATION NAME AS SHOWN IN THE ASSOCIATION AGREEMENT. BUSINESS TRUST NAME AS SHOWN IN THE TRUST AGREEMENT. ESTATE LEGAL NAME OF THE ESTATE. TRUST NAME AS SHOWN IN THE TRUST AGREEMENT. LIMITED LIABILITY COMPANY NAME AS SHOWN IN THE ARTICLES OF ORGANIZATION. RESTRICTED PROFESSIONAL COMPANY NAME AS SHOWN IN THE ARTICLES OF ORGANIZATION. GOVERNMENT OFFICIAL/LEGAL NAME OF THE ORGANIZATION. 2. 3. 4. 5. 6. New Registration: An enterprise never registered with the PA Department of Revenue or the PA Department of Labor & Industry must complete Sections 1 through 10 and additional sections as appropriate. Adding Tax(es) and Service(s): A registered enterprise adding tax(es) and service(s) must complete Sections 1 through 6 and additional sections as appropriate. Reactivating Tax(es) and Service(s): A registered enterprise reactivating tax(es) and service(s) must complete Sections 1 through 6 and additional sections as appropriate. Adding Establishment(s): A registered enterprise adding establishment location(s) must complete Sections 1 through 6 and Section 17, Multiple Establishment Information. Information Update: A registered enterprise providing changes in demographic or other information must complete Sections 1 through 6 and additional sections as appropriate. Did this Enterprise: An enterprise acquiring the business of another enterprise in whole or in part must complete Section 14, Predecessor/Successor Information. The business can be acquired by purchase, consolidation, merger, gift, or change in legal structure. A stock acquisition alone does not constitute a transfer of the business. Check the appropriate box to indicate the business operation of the enterprise. If yes: A newly formed enterprise must complete Sections 1 through 10, Section 14 and additional sections as appropriate. A previously registered enterprise must complete Sections 1 through 6, 10, 14 and additional sections as appropriate. An enterprise requesting the PA Unemployment Compensation (UC) experience record and reserve account balance of a predecessor (prior owner) must also complete Section 15, Application for PA UC Experience Record and Reserve Account Balance of Predecessor. SECTION 2 – ENTERPRISE INFORMATION 1. 2. 3. 4. Date of First Operations: Enter the first date the enterprise conducted any activity. This includes start-up operations prior to opening for business. Date of First Operations in PA: Enter the first date the enterprise conducted any activity in PA or employed PA residents. This includes start-up operations prior to opening for business. Enterprise Fiscal Year End: Enter the month (January, February, etc.) used by the enterprise to designate the end of its accounting period. Enterprise Legal Name: Enter the legal name of the enterprise. 5. Federal EIN: Enter the Federal Employer Identification Number (EIN) assigned to the enterprise by the Internal Revenue Service. If the enterprise does not have an EIN, enter “N/A”. If the enterprise has made application for an EIN, enter “Applied For”. 6. Enterprise Trade Name: Enter the name by which the enterprise is commonly known (doing business as, trading as, also known as), if it is a name other than the legal name. If the enterprise has a fictitious name registered with the PA Department of State, enter it here. If the trade name is the same as the legal name, enter “Same”. 7. Enterprise Telephone Number: Enter the telephone number for the enterprise. 8. Enterprise Street Address: Enter the physical location of the enterprise. A post office box is not acceptable. 9. Enterprise Mailing Address: Enter the address where the enterprise prefers to receive mail, if at an address other than the enterprise street address. A post office box is acceptable. If the mailing address is the same as the enterprise street address, enter “Same”. To indicate multiple mailing addresses and the purposes, attach a separate 8 1/2 X 11 sheet and identify the purpose of each. For example, an enterprise may want tax forms or licenses mailed to the enterprise address, but payroll-related forms such as Unemployment Compensation returns mailed to the address of a particular payroll service. 10. Location of Enterprise Records: Enter the street address where the enterprise records are kept. A post office box is not acceptable. If the records are kept at the enterprise street address, enter “Same”. 11. Establishment Name: Enter the name by which the establishment is known to the public; for example, the name on the front of the store. If the same as the enterprise legal name, enter “Same”. 12. Number of Establishments: Enter the number of establishments. If the enterprise has more than one establishment conducting business in PA or employing PA residents, refer to the instructions and complete Section 17, Multiple Establishment Information. 18 American LegalNet, Inc. www.FormsWorkFlow.com 13. PA School District: Enter the school