PLCB-1898 9/13 COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA LIQUOR CONTROL BOARD TAX CERTIFICATION STATEMENT (SEE INSTRUCTIONS ON REVERSE) BUREAU OF LICENSING A completed Tax Certification Statement must accompany all applications for new licenses or transfers, as required by Section 477 of the Liquor Code. Failure to provide the requested information and/or any outstanding state income, corporation, sales or unemployment compensation tax obligations (including failure to file or register) will cause your application to be rejected. If additional space is needed, please use white 8½" x 11" paper. Type or print all information requested. 1. LICENSEE (APPLICANT) NAME 2. BUSINESS PHONE NO. AREA CODE 3. TRADE/FICTITIOUS NAME (IF ANY) 4. LICENSED ADDRESS (STREET, RURUAL ROUTE, P.O. BOX NO.) (POST OFFICE) (STATE) (ZIP) 5. TYPE OF APPLICATION FILED NEW TRANSFER IF A TRANSFER BUYER SELLER 6. LCB LICENSE NUMBER (IF NONE, CHECK HERE ) 7. TYPE OF ENTITY SOLE PROPRIETOR LIMITED LIABILITY COMPANY PARTNERSHIP CORPORATION LIMITED LIABILITY PARTNERSHIP CLUB 8. LIST LICENSEE NAME (PRINT) SOCIAL SECURITY NUMBER COMPLETE ALL BLOCKS 9. LIST THE FOLLOWING STATE TAX IDENTIFICATION NUMBERS (ALL ITEMS: A,B,C, AND D MUST BE COMPLETED). A. SALES TAX LICENSE (8 DIGITS) N/A C. CORPORATE BOX/BUSINESS PARTNER NUMBER N/A B. EMPLOYER ID (EIN) (9 DIGITS) N/A D. UNEMPLOYMENT COMPENSATION ACCOUNT NUMBER N/A 10. If you currently have a License, do you have employees or have you employed any employees since you filed your last renewal application? YES NO 11. AFFIRMATION: I swear or affirm, subject to the penalties provided by 18 Pa. C.S. §4904, and 47 P.S. §403(h) and/or 4-436(j) and/or §7-704, that all information required herein has been provided, and with respect to all State taxes to which applicant is subject, all tax reports have been filed, and all State taxes have been paid, or are subject to a timely administrative or judicial appeal, or are subject to a duly approved deferred payment plan. SIGNATURE TITLE DATE American LegalNet, Inc. www.FormsWorkFlow.com SECTION 477 OF THE LIQUOR CODE REQUIRES THE BOARD NOT TO APPROVE ANY APPLICATION FOR A GRANT OR RENEWAL OR TRANSFER OF A LICENSE WHERE THE APPLICANT HAS FAILED TO PROVIDE ANY OF THE INFORMATION REQUIRED (ON THE REVERSE), OR HAS FAILED TO FILE REQUIRED STATE TAX REPORTS OR TO PAY CERTAIN STATE TAXES. IF A TRANSFER APPLICATION, THE TERM "APPLICANT" INCLUDES THE TRANSFEROR AND TRANSFEREE. BOTH THE TRANSFEROR AND TRANSFEREE ARE REQUIRED TO FILE THE TAX CERTIFICATION STATEMENT. THESE PROVISIONS ALSO APPLY TO ANY MANAGEMENT COMPANY UTILIZED BY THE APPLICANT, INCLUDING BOTH THE TRANSFEROR AND THE TRANSFEREE. A MANAGEMENT COMPANY IS DEFINED AS "ANY ENTITY EMPLOYED OR OTHERWISE CONTRACTED BY A LICENSEE TO OPERATE, MANAGE OR SUPERVISE ALL OR PART OF THE OPERATION OF THE LICENSED PREMISES." PLCB-1898A, "TAX CERTIFICATION STATEMENT FOR MANAGEMENT COMPANY" MUST BE FILED. - INSTRUCTIONS EACH AND EVERY ITEM MUST HAVE AN ENTRY!! PRINT OR TYPE ALL INFORMATION REQUESTED 1. LICENSEE NAME: List full exact name as it now appears on license if you are filing this with a transfer of the license. If you are a new applicant for license, or a transferee of an existing license, list the new ownership name. 2. BUSINESS PHONE: Include area code, then number. 3. TRADE/FICTITIOUS NAME (if any): If you are a new license applicant or a transferor or a transferee of an existing license, list your full exact trade name or registered fictitious name as shown on your application. Do not list a fictitious name unless it is registered with the Pennsylvania Department of State. 4. LICENSED ADDRESS, ETC.: If you are a new applicant for license, or a transferee of an existing license, list full exact address of proposed premises as shown on your application. 5. TYPE OF APPLICATION FILED: (Self-explanatory). 6. LCB LICENSE NUMBER (If "none," check box): If this is being filed with transfer refer to current license; NUMBER IS ABOVE NAME AT TOP CENTER OF LICENSE. If new applicant, insert "NONE." 7. TYPE OF ENTITY: (Self-explanatory). 8. LIST LICENSEE, IF SOLE PROPRIETOR: Note: A Social Security number must be listed. 9. LIST TAX ID/ACCOUNT NUMBERS: These number(s) are shown on the respective licenses/permits issued by the Pennsylvania Department of Revenue or on Quarterly Tax Form UC-2 issued by the Pennsylvania Department of Labor and Industry. Registering and electronic filing of returns and payment information can be found by visiting the PA Department of Revenue website (www.revenue.state.pa.us). 9A. Sales Tax Number is issued by the Pennsylvania Department of Revenue, Sales Tax Division. 9B. EIN Tax Number is issued by the Federal Government. NOTE: If you do not have this number, you should contact the Federal Government to secure a number and then register this number with the Pennsylvania Department of Revenue, Employer Withholding Division. If you have an EIN number but no employees, please indicate by checking the N/A box. 9C. The Corporate Box or Business Partner Number is issued by the Pennsylvania Department of Revenue, Bureau of Corporation Taxes. 9D. The Unemployment Compensation Account Number is issued by the Pennsylvania Department of Labor and Industry, Bureau of Employer Tax Operations. ALL four items (A, B, C, and D) under Question No. 9 must be completed with a number, or by checking the block "N/A" which means "NOT APPLICABLE." Any tax ID line that is blank will cause a delay in the processing of your license application. 10. (Self-explanatory) 11. AFFIRMATION: Be certain to affix your signature, title and date. It is required that the Tax Certification Statement be signed by the proprietor, partner, or responsible corporate officer. A THOROUGH ITEM BY ITEM REVIEW OF THIS FORM SHOULD BE MADE PRIOR TO SIGNING AND PLACING IN THE MAIL. FAILURE TO ANSWER ALL QUESTIONS COMPLETELY ON THIS FORM WILL CAUSE YOUR LICENSE APPLICATION TO BE REJECTED. American LegalNet, Inc. www.FormsWorkFlow.com