Pa100 Form PDF Details

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QuestionAnswer
Form NamePa100 Form
Form Length28 pages
Fillable?Yes
Fillable fields877
Avg. time to fill out36 min 28 sec
Other namespa 100 online registration, form pa 100 online, pa100 form, pa100 state pa us

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PA-100 (TR) 03-18

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.pa100.state.pa.us

P E N N S Y LV A N I A

ENTERPRISE

REGISTRATION

F O R M A N D I N S T R U C T I 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

PE N NSYLVA NIA E NTERPRISE REGISTRATIO 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 previ- ously 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

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.

•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.

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 complete the registration form:

• New registrants must complete every item in sections 1 through 10 and additional sections as indicated.

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

•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 ser- vice 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.

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 sequen- tial 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 Depart- ment of State at (717) 787-1057, or visit www.paopenforbusiness.state.pa.us.

TABLE OF

 

 

Form

Inst.

Section

Page

Page

 

mailing Address

. . . . . .

front Cover

 

Taxes and services (definitions & requirements) .

. . . . . .

.2-3

1

Reason for this Registration

. . . . .4

. . . . .

. .18

2

enterprise information

. . . . .4

. . . .18-19

3

Taxes & services

. . . . .4

. . . . .

. .19

4

Authorized signature

. . . . .4

. . . . .

. .19

5

business structure

. . . . .5

. . . . .

. .19

6

owners, Partners, shareholders, officers,

. . . . .5

. . . . .

. .19

 

Responsible Party information

 

 

 

6a

Additional owners, Partners, shareholders,

. . . .11 . . . .

. .19

 

officers, Responsible Party information

 

 

 

7establishment business Activity information . . . .5 . . . .20-21

8 establishment sales information . . . . . . . . . . . . .6 . . . . . . .22 9 establishment employment information . . . . . . . .6 . . . . . . .22 10 bulk sale/Transfer information . . . . . . . . . . . . . .6 . . . . . . .22 11 Corporation information . . . . . . . . . . . . . . . . . . . .7 . . . . . . .22 12 Reporting & Payment methods . . . . . . . . . . . . . .7 . . . . . . .22

CO NTE NTS

 

 

Form

Inst.

Section

Page

Page

13

government structure

. .7

. .23

14

Predecessor/successor information

. .8

. .23

15

Application for PA uC experience Record & . .

. .9

. .23

 

Reserve Account balance of Predecessor

 

 

16

unemployment Compensation Partial

. .9

. .24

 

Transfer information

 

 

17

multiple establishment information

. .10-11 . .

. .24

18sales 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 Dealer’s license

13

. . . . . .25

20

small games of Chance license/Certificate . . . .

14-15 . . .25

21

motor Carrier Registration & Decal/motor

16

. . .25-26

 

fuels license & Permit

 

 

22

sales Tax exempt status for Charitable and . . . .

17

. . . . . .26

 

Religious organizations

 

 

 

Contact information

. . .

. . .26-27

1

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

 

REQUIREMENTS

 

SECTIONS TO

 

 

COMPLETE

 

 

 

 

 

•

CigAReTTe DeAleR’s

•

seCTion 19

CIGARETTE TAX is An exCise TAx imPoseD on The sAle oR Possession of

 

liCense

 

 

CigAReTTes. A DeAleR is Any CigAReTTe sTAmPing AgenT, wholesAleR,

 

 

 

 

oR ReTAileR.

•

sAles TAx liCense

•

seCTion 18

 

 

(ReTAileR)

 

 

 

 

 

 

 

CORPORATE NET INCOMEAND CAPITAL STOCK FRANCHISE TAXESARe imPoseD

•

RegisTRATion wiTh

 

 

 

PA DePARTmenT of sTATe

 

 

on DomesTiC AnD foReign CoRPoRATions, CeRTAin business TRusTs, AnD

 

 

 

 

 

•

seCTion 11

limiTeD liAbiliTy ComPAnies whiCh ARe RegisTeReD AnD/oR TRAnsACTing

•

foRms musT be obTAineD

 

 

business wiThin The CommonweAlTh of PennsylvAniA. subJeCTiviTy To

 

fRom PA DePARTmenT of

 

 

 

sTATe

 

 

sPeCifiC CoRPoRATion TAxes is DeTeRmineD by The TyPe of CoRPoRATe

 

 

 

 

 

 

 

oRgAniZATion AnD The ACTiviTy ConDuCTeD.

 

 

 

 

• 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

•

RegisTRATion wiTh feDeR-

 

 

insuRAnCe ComPAnies ARe subJeCT To The TiTle insuRAnCe ComPAny

 

Al oR sTATe AuThoRiTy

 

 

shARes TAx. The muTuAl ThRifT insTiTuTions TAx is imPoseD on sAv-

 

 

 

 

ThAT gRAnTeD ChARTeR

 

 

ings insTiTuTions, sAvings bAnKs, sAvings AnD loAn AssoCiATions,

 

 

 

 

 

 

 

AnD builDing AnD loAn AssoCiATions ConDuCTing business in Penn-

 

 

 

 

sylvAniA. CReDiT unions ARe noT subJeCT To TAx.

 

 

 

 

• GROSS PREMIUMS TAX is levieD on DomesTiC AnD foReign insuRAnCe

•

RegisTRATion wiTh

 

 

ComPAnies. The yeARly gRoss PRemiums ReCeiveD foRm The TAx

 

PA DePARTmenT of

 

 

bAse. gRoss PRemiums ARe PRemiums, PRemium DePosiTs, oR

 

 

 

 

insuRAnCe

 

 

AssessmenTs, foR business TRAnsACTeD in PennsylvAniA.

 

 

 

 

 

 

 

• GROSS RECEIPTS TAX is levieD on PiPeline, ConDuiT, wATeR nAvigATion

 

 

 

 

AnD TRAnsPoRTATion ComPAnies; TelePhone, TelegRAPh AnD mobile

•

RegisTRATion wiTh PA

 

 

TeleCommuniCATions ComPAnies; eleCTRiC lighT, wATeR PoweR AnD

 

PubliC uTiliTy

 

 

hyDRoeleCTRiC ComPAnies; AnD fReighT AnD oil TRAnsPoRTATion

 

Commission

 

 

ComPAnies.

 

 

 

 

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 fuR-

 

 

 

 

nishing uTiliTy seRviCes. PennsylvAniA imPoses This TAx on PubliC

•

RegisTRATion wiTh PA

 

 

uTiliTy ReAlTy in lieu of loCAl ReAl esTATe TAxes AnD DisTRibuTes

 

PubliC uTiliTy Commission

 

 

The loCAl ReAlTy TAx eQuivAlenT To loCAl TAxing AuThoRiTies.

 

 

 

 

• OTHER CORPORATION TAXES: This gRouP is ComPoseD PRimARily of

•

RegisTRATion wiTh PA

 

 

The CoRPoRATe loAns TAx, The CooPeRATive AgRiCulTuRAl AssoCiA-

 

DePARTmenT of sTATe

 

 

Tion AnD eleCTRiC CooPeRATive CoRPoRATion TAxes.

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER WITHHOLDING is The wiThholDing of PennsylvAniA PeRsonAl

 

 

 

 

inCome TAx by emPloyeRs fRom ComPensATion PAiD To PennsylvAniA

 

 

•

seCTion 9

ResiDenT emPloyees foR woRK PeRfoRmeD insiDe oR ouTsiDe of Penn-

 

 

 

 

 

 

sylvAniA 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 Penn-

 

 

 

 

sylvAniA, exCePT Those DeliveReD To exemPT PuRChAseRs. liQuiD fuels

•

liQuiD fuels AnD fuels

•

seCTion 21

inCluDe gAsoline, gAsohol, JeT fuel, AnD AviATion gAsoline. fuels

 

TAx PeRmiT

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

•

ifTA liCense AnD

 

 

oR enTeRPRise oPeRATing A QuAlifieD moToR vehiCle useD, DesigneD,

 

ifTA DeCAls

 

 

oR mAinTAineD foR The TRAnsPoRTATion of PeRsons oR PRoPeRTy

 

 

 

 

 

 

 

wheRe (A) The PoweR uniT hAs Two Axles AnD A gRoss oR RegisTeReD

•

PA non-ifTA vehiCle

•

seCTion 21

 

 

gRoss weighT gReATeR ThAn 26,000 PounDs, (b) The PoweR uniT hAs

 

RegisTRATion AnD PA non-

 

 

ThRee Axles oR moRe RegARDless of weighT, oR (C) vehiCles ARe useD

 

 

 

 

ifTA DeCAls

 

 

in CombinATion AnD The DeClAReD CombinATion weighT exCeeDs 26,000

 

 

 

 

 

 

 

PounDs oR The gRoss weighT of The vehiCles exCeeDs 26,000 PounDs.

 

 

 

 

 

 

 

 

 

2

PROMOTER is Any enTeRPRise engAgeD in RenTing, leAsing, oR gRAnTing PeR-

 

 

 

 

mission To Any PeRson To use sPACe AT A show foR The DisPlAy oR foR The

•

PRomoTeR liCense

•

seCTion 18

sAle of TAngible PeRsonAl PRoPeRTy oR seRviCes.

 

 

 

 

 

 

 

 

 

PUBLIC TRANSPORTATION ASSISTANCE FUND TAX is A TAx oR fee imPoseD on eACh

•

sAles use AnD hoTel

 

 

sAle in PennsylvAniA of new TiRes foR highwAy use, on The leAse of moToR

 

oCCuPAnCy TAx liCense

 

 

vehiCles, AnD on The RenTAl of moToR vehiCles. The TAx is Also levieD on The

 

•

seCTion 18

 

PubliC TRAnsPoRTATion

sTATe TAxAble vAlue of uTiliTy ReAlTy of enTeRPRises subJeCT To The PubliC

•

 

 

uTiliTy ReAlTy TAx AnD on PeTRoleum Revenue of oil ComPAnies.

 

AssisTAnCe TAx liCense

 

 

 

 

 

 

 

REPORTING AND PAYMENT METHODS offeR The enTeRPRise The AbiliTy To file

 

 

 

 

CeRTAin TAx ReTuRns AnD mAKe eleCTRoniC PAymenTs ThRough The eleCTRon-

 

 

 

 

iC TAx infoRmATion AnD DATA exChAnge sysTem (e-TiDes) oR The Telefile

 

 

 

 

sysTem. eleCTRoniC PAymenT mAy Also be mADe ThRough eleCTRoniC funDs

•

AuThoRiZATion

•

seCTion 12

TRAnsfeR (efT) oR CReDiT CARD. unemPloymenT ComPensATion (uC) wAges mAy

 

AgReemenT

 

 

 

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.

 

 

 

 

 

 

 

 

 

SALES TAX isAn exCise TAx imPoseD on The ReTAil sAle oR leAse of TAxAble, TAn-

•

sAles use AnD hoTel

•

seCTion 18

gible PeRsonAl PRoPeRTy, AnD on sPeCifieD seRviCes.

 

oCCuPAnCy TAx liCense

 

 

 

 

 

 

• HOTEL OCCUPANCY TAX is An exCise TAx imPoseD on eveRy hoTel oR moTel

•

sAles use AnD hoTel

 

seCTion 18

Room oCCuPAnCy less ThAn 30 ConseCuTive DAys.

 

oCCuPAnCy TAx liCense

•

 

 

 

 

• LOCALSALES TAX mAy be imPoseD in PhilADelPhiAoRAllegheny CounTies, in

•

sAles use AnD hoTel

 

 

ADDiTion To The sTATe sAles AnD use TAx, on The ReTAil sAle oR use of TAn-

 

 

gible PeRsonAl PRoPeRTy AnD seRviCes AnD on hoTel/moTel oCCuPAnCies.

 

oCCuPAnCy TAx liCense

•

seCTion 18

 

 

 

 

 

 

 

 

 

SALES TAX EXEMPT STATUS FOR CHARITABLEAND RELIGIOUS ORGANIZATIONS is The

 

 

 

 

QuAlifiCATion of An insTiTuTion of PuRely PubliC ChARiTy To be exemPT fRom

•

CeRTifiCATe of exemPT

•

seCTion 22

sAles AnD use TAx on The PuRChAse of TAngible PeRsonAl PRoPeRTy oR seR-

 

sAles TAx sTATus

 

 

 

viCes foR use in ChARiTAble ACTiviTy.

 

 

 

 

 

 

 

 

 

• smAll gAmes of ChAnCe

 

 

SMALL GAMES OF CHANCE is The RegulATion of limiTeD gAmes of ChAnCe ThAT

 

DisTRibuToR liCense

 

 

QuAlifieD ChARiTAble AnD non-PRofiT oRgAniZATions CAn oPeRATe in Penn-

 

AnD/oR

•

seCTion 20

sylvAniA.

•

mAnufACTuReR

 

 

 

 

 

 

 

RegisTRATion CeRTifiCATe

 

 

 

 

 

 

 

TRANSIENT VENDOR is Any enTeRPRise whose business sTRuCTuRe is sole PRo-

 

 

 

 

PRieToR oR PARTneRshiP, noT hAving A PeRmAnenT PhysiCAl business loCATion

•

TRAnsienT venDoR

•

seCTion 18

in PennsylvAniA, whiCh sells TAxAble, TAngible PeRsonAl PRoPeRTy oR PeR-

 

CeRTifiCATe

 

 

 

foRms TAxAble seRviCes in PennsylvAniA.

 

 

 

 

 

 

 

 

 

UNEMPLOYMENT COMPENSATION (UC) PRoviDes A funD fRom whiCh ComPensATion

 

 

 

 

is PAiD To woRKeRs who hAve beCome unemPloyeD ThRough no fAulT of TheiR

 

 

 

 

own. ConTRibuTionsARe ReQuiReD To be mADe byAll emPloyeRs who PAy wAges

 

 

•

seCTions 7, 9,

To inDiviDuAls woRKing in PA AnD whose seRviCes ARe CoveReD unDeR The uC

•

APPliCATion foR

 

if APPliCAble

lAw. This TAx mAy inCluDe emPloyee ConTRibuTions wiThhelD by emPloyeRs

 

10 AnD 14

fRom eACh emPloyee’s gRoss wAges. (see emPloyeR wiThholDing DefiniTion)

 

exPeRienCe ReCoRD AnD

 

 

 

ReseRve ACCounT

 

 

 

 

•

seCTions 14,

• APPLICATION FOR PA UC EXPERIENCE RECORD AND RESERVE ACCOUNT BAL-

 

bAlAnCe of PReDeCessoR

 

 

15. if APPliC-

ANCE enAbles The RegisTeRing enTeRPRise To benefiT fRom A PReDeCes-

 

 

 

 

 

 

Able, 16

soR’s 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

•

use TAx ACCounT

•

seCTion 18

sAles TAx hAs noT been PAiD.

 

 

 

 

 

 

 

 

 

VEHICLE RENTAL TAX is imPoseD on RenTAl ConTRACTs by enTeRPRises hAving

•

sAles use AnD hoTel

 

 

AvAilAble foR RenTAl: (1) 5 oR moRe moToR vehiCles DesigneD To CARRy 15 oR

 

oCCuPAnCy TAx liCense

•

seCTion 18

less PAssengeRs, oR (2) TRuCKs, TRAileRs, oR semi-TRAileRs useD in The TRAns-

 

 

 

•

PTA liCense

 

 

PoRTATion 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 TAngi-

•

wholesAleR CeRTifiCATe

•

seCTion 18

ble PeRsonAl PRoPeRTy oR seRviCes foR ResAle TAx-fRee when useD in The

 

 

 

 

noRmAl CouRse of The enTeRPRise’s business.

 

 

 

 

 

 

 

 

 

WORKERS’ 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 woRKeRs’ ComPensA-

 

 

 

 

Tion CoveRAge ARe immune To lAwsuiTs flowing fRom woRK-RelATeD inJuRies

 

 

 

 

oTheR ThAn Those ACTions fileD unDeR The woRKeRs’ ComPensATion ACT.

 

 

 

 

eveRy emPloyeR liAble unDeR The PA woRKeRs’ ComPensATion ACT shAll

•

woRKeRs’ ComPensATion

•

seCTion 9

insuRe The PAymenT of ComPensATion wiTh The sTATe woRKmen’s insuRAnCe

 

CoveRAge

 

 

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, woRKeRs’ ComPensATion musT be ConTinuAlly mAinTAineD wiTh

 

 

 

 

no inTeRRuPTion in CoveRAge.

 

 

 

 

 

 

 

 

 

3

PA-100 (TR) 03-18

MAIL COMPLETED APPLICATION TO:

DEPARTMENT OF REVENUE

BUREAU OF BUSINESS TRUST FUND TAXES

PO BOX 280901

HARRISBURG, PA 17128-0901

TYPE OR PRINT LEGIBLY, USE BLACK INK

COMMONWEALTH OF PENNSYLVANIA

PA ENTERPRISE

REGISTRATION FORM

DEPARTMENT USE ONLY

RECEIVED DATE

DePARTmenT of Revenue &

DePARTmenT of lAboR AnD inDusTRy

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.

o new RegisTRATion

2.

o ADDing TAx(es) & seRviCe(s)

3.

o ReACTivATing TAx(es) & seRviCe(s)

4.

o

ADDing esTAblishmenT(s)

5.

o

infoRmATion uPDATe

6. DiD This enTeRPRise:

o yes

o no

ACQuiRe All oR PART of AnoTheR business?

o yes

o no

ResulT fRom A ChAnge in legAl sTRuCTuRe (foR exAmPle, fRom inDiviDuAl

 

 

PRoPRieToR To CoRPoRATion, PARTneRshiP To CoRPoRATion, CoRPoRATion

 

 

To limiTeD liAbiliTy ComPAny, eTC)?

o yes

o no

unDeRgo A meRgeR, ConsoliDATion, DissoluTion, oR oTheR ResTRuCTuRing?

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

13. PA sChool DisTRiCT

14. PA muniCiPAliTy

 

 

 

esTAblishmenTs *

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*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

oCigAReTTe DeAleR’s liCense

oCoRPoRATion TAxes

oemPloyeR wiThholDing TAx/1099 misC

ofuels TAx PeRmiT

oliQuiD fuels TAx PeRmiT

omoToR CARRieRs RoAD TAx/ifTA

oPRomoTeR liCense

oPubliC TRAnsPoRTATion AssisTAnCe TAx liCense

osAles TAx exemPT sTATus

SECTION 4 – AUTHORIZED SIGNATURE

o

o o o o o o o

sAles, use, hoTel oCCuPAnCy TAx liCense

smAll gAmes of ChAnCe liC./CeRT.

TRAnsienT venDoR CeRTifiCATe

unemPloymenT ComPensATion

use TAx

vehiCle RenTAl TAx

wholesAleR CeRTifiCATe

woRKeRs’ ComPensATion CoveRAge

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

TiTle

 

 

(

)

 

 

 

 

TyPe oR PRinT nAme

e-mAilADDRess

DATe

 

 

 

 

TyPe oR PRinT PRePAReR’s nAme

 

 

TiTle

 

 

 

DAyTime TelePhone numbeR

e-mAilADDRess

DATe

(

)

 

 

 

4

PA-100 (TR) 03-18

 

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.

o sole PRoPRieToRshiP (inDiviDuAl)

o geneRAl PARTneRshiP

o AssoCiATion

o limiTeD liAbiliTy ComPAny

 

o CoRPoRATion (sec. 11)

o limiTeD PARTneRshiP

o business TRusT

STATE WHERE CHARTERED

 

 

 

 

o goveRnmenT (sec. 13)

o limiTeD liAbiliTy PARTneRshiP

o esTATe

o ResTRiCTeD PRofessionAl ComPAny

 

 

 

o JoinT venTuRe PARTneRshiP

 

STATE WHERE CHARTERED

 

o PRofiT

o non-PRofiT

 

 

 

2.

is The enTeRPRise oRgAniZeD foR PRofiT oR non-PRofiT?

 

 

3.

o yes

o 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 inDiviDuAlAnD/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. ADDITIONALSPACE ISAVAILABLE IN SECTION 6A, PAGE 11.

1.

nAme

 

 

 

2. soCiAl seCuRiTy numbeR

3.

DATe of biRTh *

 

4.

feDeRAl ein

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

o owneR

o offiCeR

6. TiTle

 

 

 

7. effeCTive DATe

8.

PeRCenTAge of

 

9.

effeCTive DATe of

 

o PARTneR

o shAReholDeR

 

 

 

 

of TiTle

 

owneRshiP

 

 

owneRshiP

 

o ResPonsible PARTy

 

 

 

 

 

 

 

 

 

%

 

 

10. home ADDRess (street)

 

 

CiTy/Town

 

 

CounTy

 

 

sTATe

 

ZiP CoDe + 4

 

 

 

 

 

 

 

 

 

 

11. This PeRson is ResPonsible To RemiT/mAinTAin:

o sAles TAx

o emPloyeR wiThholDing TAx

o moToR fuel TAxes

owoRKeRs’ ComPensATion CoveRAge

* DATe of biRTh ReQuiReD only if APPlying foR A CigAReTTe wholesAle DeAleR’s 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 PABUSINESS 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

%

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 ESTABLISHMENT’S ReCeiPTs oR Revenues RePResenT of The TOTAL PAReCeiPTs 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 PeRCenT- Age of ConsTRuCTion ACTiviTy ThAT is ResiDenTiAlAnD/oR CommeRCiAl.

 

___________________ % new

+

__________________ % RenovATive

=

100%

 

 

___________________ % ResiDenTiAl

+

__________________ % CommeRCiAl

=

100%

 

 

 

 

 

 

4. o yes o no

Does This enTeRPRise wAnT To beCome A PennsylvAniA loTTeRy ReTAileR?

 

 

 

 

 

 

 

 

 

 

5

PA-100 (TR) 03-18

 

DePARTmenT use only

 

 

enTeRPRise nAme

 

 

SECTION 8 – ESTABLISHMENT SALES INFORMATION

1.

o yes

o no

is This esTAblishmenT selling TAxAble PRoDuCTs oR offeRing TAxAble seRviCes To ConsumeRs fRom A loCATion

 

 

 

IN PENNSYLVANIA? if yes, ComPleTe seCTion 18.

2.

o yes

o 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. o yes o

2. o yes o

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

.$

.00

g.nAme of woRKeRs’ ComPensATion insuRAnCe ComPAny

1. PoliCy numbeR _________________________________effeCTive sTART DATe __________________enD DATe ___________________

2. AgenCy nAme ______________________________________________________DAyTime TelePhone numbeR ( )

mAiling ADDRess _____________________________________CiTy/Town ______________________sTATe _____ZiP CoDe + 4________

3.if This enTeRPRise Does noT hAve woRKeRs’ ComPensATion insuRAnCe, CheCK one:

 

a.

This esTAblishmenT emPloys only exCluDeD woRKeRs

o

 

b.

. . . . . . . . .This esTAblishmenT hAs ZeRo emPloyees

o

 

c.

This esTAblishmenT ReCeiveD APPRovAl To self-insuRe by The PA buReAu of

 

 

 

 

woRKeRs’ ComPensATion

o

 

 

if iTem 3c. is CheCKeD, PRoviDe PA woRKeRs’ ComPensATion buReAu CoDe

 

 

 

no

Does This esTAblishmenT emPloy PA ResiDenTs who WORK OUTSIDE OF PENNSYLVANIA?

 

 

 

if yes, inDiCATe:

 

 

 

a.

DATe wAges fiRsT PAID (mm/DD/yyyy)

 

 

 

b.

. . . . . . . . . .DATe wAges ResumeD following A bReAK in emPloymenT

 

 

 

c.

esTimATeD gRoss wAges PeR QuARTeR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$

.00

3.

o yes

o no

Does This esTAblishmenT PAy RemuneRATion foR seRviCes To PeRsons you Do noT ConsiDeR emPloyees?

 

 

 

 

 

 

if yes, exPlAin The seRviCes PeRfoRmeD

 

 

 

 

 

4.

o yes

o no

DoesThisesTAblishmenTRePoRTnon-ResiDenTwiThholDingonnon-emPloyeeComPensATion,businessinComeoRleAsePAymenTs?

 

 

 

 

 

 

 

 

 

 

 

 

PART 2

 

 

 

 

 

 

 

 

 

 

 

1.

o yes

o 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.

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.

o yes

o 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.

o yes

o no

DiD The enTeRPRise ACQuiRe 51% oR moRe of The TOTALASSETS 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

CiTy/Town

sTATe

ZiP CoDe + 4

6. DATe AsseTs ACQuiReD

7. AsseTs ACQuiReD:

 

 

 

 

o ACCounTs ReCeivAble

o eQuiPmenT

o invenToRy

o nAme AnD/oR gooDwill

o ConTRACTs

o fixTuRes

o leAses

o ReAl esTATe

o CusTomeRs/ClienTs

o fuRniTuRe

o mAChineRy

o 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

PA-100 (TR) 03-18

 

DePARTmenT use only

 

 

enTeRPRise nAme

 

 

SECTION 11 – CORPORATION INFORMATION

1. DATe of inCoRPoRATion

2. sTATe of inCoRPoRATion

3. CeRTifiCATe of AuThoRiTy DATe

 

 

(non-PA CoRP.)

 

 

 

4. CounTRy of inCoRPoRATion

5. o yes

o no

is This CoRPoRATion's sToCK PubliCly TRADeD?

6. CheCK The APPRoPRiATe box(es) To DesCRibe This CoRPoRATion:

CoRPoRATion: o sToCK

o PRofessionAl

bAnK: o sTATe

muTuAl ThRifT: o sTATe

insuRAnCe

o PA

o non-sToCK

o CooPeRATive

o feDeRAl

o feDeRAl

ComPAny:

o non-PA

o mAnAgemenT

o sTATuToRy Close

 

 

 

 

7. s CoRPoRATion: o feDeRAl

inACCoRDAnCe wiThACTno.67 of 2006, A CoRPoRATion wiTh feDeRAl sub-ChAPTeR s sTATus is ConsiDeReD A PA s CoR-

 

PoRATion. 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 DEPART- MENT 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.

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 fol- lowing 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. o yes

o

b. o yes

o

2. o yes

o

no

Does This enTeRPRise meeT The DePARTmenT of Revenue’s ReQuiRemenTs foR eleCTRoniC PAymenTs?

no

Does This enTeRPRise wAnT To PARTiCiPATe in The DePARTmenT of Revenue’s 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 & inDusTRy’s oPTion of finAnCing uC CosTs

 

unDeR The ReimbuRsemenT meThoD in lieu of The ConTRibuToRy meThoD? foR moRe DeTAils, RefeR To seCTion 12

 

insTRuCTions.

The DePARTmenT of lAboR & inDusTRy ReQuiRes ThATAny 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 & inDusTRy’s foRmAT. ConTACT The mAg- neTiC 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:

 

 

 

 

o goveRnmenT boDy

o goveRnmenT owneD enTeRPRise

o goveRnmenT & PRivATe seCToR

 

 

 

owneD enTeRPRise

2.

is The goveRnmenT:

 

 

 

 

o DomesTiC/usA

o foReign/non-usA

o mulTi-nATionAl

3.

if DomesTiC, is The goveRnmenT:

 

 

 

 

o feDeRAl

loCAl: o CounTy

o boRough

 

o sTATe goveRnoR's JuRisDiCTion

o CiTy

o sChool DisTRiCT

 

o sTATe non-goveRnoR's JuRisDiCTion

o Town

o oTheR

 

 

 

o TownshiP

 

 

7

PA-100 (TR) 03-18

 

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

sTATe

ZiP CoDe + 4

6.

sPeCify how The business wAs ACQuiReD:

o PuRChAse

o ChAnge in legAl sTRuCTuRe

 

o ConsoliDATion

o gifT

o meRgeR

o iRC seC. 338 eleCTion

o oTheR (sPeCify)

 

7.

o ACQuisiTion DATe

 

 

 

 

 

 

 

 

8.

PeRCenTAge of The PReDeCessoR's ToTAl business (PAAnD 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 PReDeCessoR’s business ACTiviTy in The PA business ThAT wAs ACQuiReD?

11. AsseTs ACQuiReD:

o ACCounTs ReCeivAble

o eQuiPmenT

o leAses

o oTheR (sPeCify)

 

o ConTRACTs

o fixTuRes

o mAChineRy

 

 

o CusTomeRs/ClienTs

o fuRniTuRe

o nAme AnD/oR gooDwill

 

 

o emPloyees

o invenToRy

o ReAl esTATe

 

12.o yes

o no

hAs The PReDeCessoR CeAseD PAying wAges in PA? if yes, enTeR The DATe PA wAges CeAseD,

 

 

if Known.

 

 

13.o yes

o 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. o yes

o 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. o yes

o 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. o yes

o 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 enTeRPRise’s uC TAxAble wAge bAse foR The CAlenDAR yeAR of ACQuisiTion wiThouT TRAnsfeRRing The PReDeCessoR's exPeRienCe ReCoRD AnD ReseRve ACCounT bAlAnCe.

8

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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 enTeRPRise’s 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 PReDeCessoR’s 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 enTeRPRiseACQuiReD only PART of The PReDeCessoR's PennsylvAniA(PA) businessAnD is mAKingAPPliCATion 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________

 

 

yeAR________

 

 

yeAR________

 

 

yeAR________

 

 

yeAR________

 

 

 

 

 

 

 

 

 

 

 

 

of TRAnsfeR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QuARTeRs

 

 

 

QuARTeRs

 

 

 

QuARTeRs

 

 

 

QuARTeRs

 

 

 

QuARTeRs

 

 

 

QuARTeRs

 

1

 

2

3

 

4

1

 

2

3

 

4

1

 

2

3

 

4

1

 

2

3

 

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________

 

 

yeAR________

 

 

yeAR________

 

 

yeAR________

 

 

yeAR________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

of TRAnsfeR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QuARTeRs

 

 

 

QuARTeRs

 

 

 

QuARTeRs

 

 

 

QuARTeRs

 

 

 

QuARTeRs

 

 

 

QuARTeRs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

2

3

 

4

1

 

2

3

 

4

1

 

2

3

 

4

1

 

2

3

 

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

PA-100 (TR) 03-18

 

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enTeRPRise nAme

 

 

SECTION 17 – MULTIPLE ESTABLISHMENT INFORMATION

COMPLETE THIS SECTION FOR EACHADDITIONALESTABLISHMENT CONDUCTING BUSINESS IN PAOR EMPLOYING PARESIDENTS. PHOTOCOPYTHIS SECTIONAS NECESSARY.

.PART 1 ESTABLISHMENT INFORMATION

1.

esTAblishmenT nAme (doing business as)

 

2. DATe of fiRsT oPeRATions

3. TelePhone numbeR

 

 

 

 

(

)

 

 

 

 

 

 

4.

sTReeT ADDRess

CiTy/Town

CounTy

sTATe

ZiP CoDe + 4

 

 

 

 

 

 

5. PA sChool DisTRiCT

6. PA muniCiPAliTy

PART 2 ESTABLISHMENT BUSINESS ACTIVITY INFORMATION

REFER TO THE INSTRUCTIONS ON PAGES 20 & 21 TO COMPLETE THIS SECTION.

1.enTeR The PeRCenTAge eACh PABUSINESSACTIVITY RePResenTs of The ToTAl ReCeiPTs oR Revenues AT THIS esTAblishmenT. lisT PRODUCTSOR SERVICES AssoCiATeD wiTh eACh business ACTiviTyAnD 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

ToTAl100%

2.enTeR The PeRCenTAge ThAT THIS ESTABLISHMENT’S 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 PeRCenT- Age of ConsTRuCTion ACTiviTy ThAT is ResiDenTiAlAnD/oR CommeRCiAl.

___________________% new

+

__________________ % RenovATive

= 100%

___________________ % ResiDenTiAl

+

__________________ % CommeRCiAl

= 100%

 

 

 

 

10

PA-100 (TR) 03-18

 

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enTeRPRise nAme

 

 

 

 

 

 

PART 3

ESTABLISHMENT SALES INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

o yes

o no

is This esTAblishmenT selling TAxAble PRoDuCTs oR offeRing TAxAble seRviCes To ConsumeRs fRom A loCATion

 

 

 

 

IN PENNSYLVANIA? if yes, ComPleTe seCTion 18.

 

 

 

 

 

 

 

 

2.

o yes

o 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

ESTABLISHMENT EMPLOYMENT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

o yes

o 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

. . . . . . . . . . . . . . . . . . . . . . .$

 

.00

 

 

 

2.

o yes

o no

Does This esTAblishmenT emPloy PA ResiDenTs who WORK OUTSIDE OF PENNSYLVANIA?

 

 

 

 

 

 

 

 

if yes, inDiCATe:

 

 

 

 

 

 

 

 

 

 

 

 

a.

DATe wAges fiRsT PAID (mm/DD/yyyy)

. . . . . . . . . . . . . . . . . . . . . . .

 

 

 

 

 

 

 

 

 

 

b.

. .DATe wAges ResumeD following A bReAK in emPloymenT

. . . . . . . . . . . . . . . . . . . . . . .

 

 

 

 

 

 

 

 

 

 

c.

esTimATeD gRoss wAges PeR QuARTeR

. . . . . . . . . . . . . . . . . . . . . . .$

 

.00

 

 

 

3.

o yes

o no

Does This esTAblishmenT PAy RemuneRATion foR seRviCes To PeRsons you Do noT ConsiDeR emPloyees?

 

 

 

 

 

 

 

 

if yes, exPlAin The seRviCes PeRfoRmeD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART 4B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

o yes

o 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. esTimATeD benefiTs PAiD PeR QuARTeR

. . . . . . . . . . . . . $

 

 

.00

 

 

SECTION 6A – ADDITIONAL OWNERS, PARTNERS, SHAREHOLDERS, OFFICERS, AND

RESPONSIBLE PARTY INFORMATION

PRoviDe The following foR ALL inDiviDuAlAnD/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

 

 

 

2. soCiAl seCuRiTy numbeR

3.

DATe of biRTh *

 

4.

feDeRAl ein

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

o owneR

o offiCeR

6. TiTle

 

 

 

7. effeCTive DATe

8.

PeRCenTAge of

 

9.

effeCTive DATe of

 

o PARTneR

o shAReholDeR

 

 

 

 

of TiTle

 

owneRshiP

 

 

owneRshiP

 

o ResPonsible PARTy

 

 

 

 

 

 

 

 

 

%

 

 

10. home ADDRess (street)

 

 

CiTy/Town

 

 

CounTy

 

 

sTATe

 

ZiP CoDe + 4

 

 

 

 

 

 

 

 

 

 

11. This PeRson is ResPonsible To RemiT/mAinTAin:

o sAles TAx

o emPloyeR wiThholDing TAx

o moToR fuel TAxes

 

 

 

 

o woRKeRs’ ComPensATion CoveRAge

 

 

 

 

 

 

1.

nAme

 

 

 

2. soCiAl seCuRiTy numbeR

3.

DATe of biRTh *

 

4.

feDeRAl ein

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

o owneR

o offiCeR

6. TiTle

 

 

 

7. effeCTive DATe

8.

PeRCenTAge of

 

9.

effeCTive DATe of

 

o PARTneR

o shAReholDeR

 

 

 

 

of TiTle

 

owneRshiP

 

 

owneRshiP

 

o ResPonsible PARTy

 

 

 

 

 

 

 

 

 

%

 

 

10. home ADDRess (street)

 

 

CiTy/Town

 

 

CounTy

 

 

sTATe

 

ZiP CoDe + 4

 

 

 

 

 

 

 

 

 

 

11. This PeRson is ResPonsible To RemiT/mAinTAin:

o sAles TAx

o emPloyeR wiThholDing TAx

o moToR fuel TAxes

owoRKeRs’ ComPensATion CoveRAge

* DATe of biRTh ReQuiReD only if APPlying foR A CigAReTTe wholesAle DeAleR’s liCense, A smAll gAmes of ChAnCe DisTRibuToR liCense, oR A smAll gAmes of ChAnCe mAnufACTuReR CeRTifiCATe.

11

PA-100 (TR) 03-18

 

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 PennsylvAniAAnD 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

6. enD DATe

1. PRomoTeR numbeR

2. show nAme

3. CounTy

4. show ADDRess (sTReeT, CiTy, sTATe, ZiP)

5. sTART DATe

6. 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

3. sTART DATe

4. enD DATe

 

 

 

 

 

 

 

 

5. show ADDRess (sTReeT, CiTy, sTATe, ZiP)

6. CounTy

7. nbR of venDoRs

1. show nAme

2. TyPe of show

3. sTART DATe

4. enD DATe

5. show ADDRess (sTReeT, CiTy, sTATe, ZiP)

6. CounTy

7. nbR of venDoRs

ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY.

12

PA-100 (TR) 03-18

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

o ReTAil oveR-The-CounTeR

_____________________

@

$

25

eACh loCATion

$

 

 

o ReTAil oveR-The-CounTeR iTineRAnT

_____________________

@

$

25

eACh loCATion

$

 

 

o venDing mAChine (ATTACh A lisT of loCATions)

_____________________

@

$

25

eACh DeCAl

$

 

 

o wholesAleR

_____________________

@

$

500

eACh liCense

$

 

 

o 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

CounTy

sTATe

ZiP CoDe + 4

2. o yes

o no

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 CIGARETTE STAMPING AGENT

1. o yes

o no

Does The enTeRPRise PuRChAse oR sellAny CigAReTTes whiCh ARe noT PA sTAmPeD?

if yes, lisT sTATes:

13

PA-100 (TR) 03-18

 

DePARTmenT use only

 

 

enTeRPRise nAme

 

 

SECTION 20 – SMALL GAMES OF CHANCE LICENSE/CERTIFICATE

PART 1 DISTRIBUTOR AND/OR MANUFACTURER

To be ComPleTeD by AllAPPliCAnTs (DisTRibuToR AnD/oR mAnufACTuReR)

APPliCAnTs musT submiT A CoPy of The CeRTifiCATe of inCoRPoRATion, ARTiCles of inCoRPoRATion, CeRTifiCATe of AuThoRiTy (non-PA CoRPoRATions), by- lAws, 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

 

o DisTRibuToR liCense

 

 

$

2,000

 

$

 

 

o mAnufACTuReR RegisTRATion CeRTifiCATe

 

 

$

2,000

 

$

 

 

o RePlACemenT liCense

 

 

$

100

 

$

 

 

o RePlACemenT CeRTifiCATe

 

 

$

100

 

$

 

 

numbeR of bACKgRounD invesTigATions foR owneRs/offiCeRs, eTC. _____________

@

$

22

 

$

 

 

 

 

ToTAlAmounT 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 foRAll 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

o sells foR DisTRibuToR

o Commission

 

 

o sells foR mAnufACTuReR

o nonCommission

 

 

 

 

 

home ADDRess (sTReeT)

CiTy/Town

sTATe

ZiP CoDe + 4

TelePhone nbR.

 

 

 

 

(

)

nAme

TiTle

o sells foR DisTRibuToR

o Commission

 

 

o sells foR mAnufACTuReR

o nonCommission

 

 

 

 

 

home ADDRess (sTReeT)

CiTy/Town

sTATe

ZiP CoDe + 4

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.

 

o Pull-TAbs

o PunChboARDs

o DisPensing mAChines

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART 2

DISTRIBUTOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

lisT All smAll gAmes of ChAnCe mAnufACTuReRs wiTh whom The DisTRibuToR Does business.

 

 

 

 

 

mAnufACTuReR’s legAl nAme

 

 

mAnufACTuReR’s CeRTifiCATe numbeR

TelePhone numbeR

 

 

 

 

 

M-

 

(

)

 

 

 

 

 

 

 

 

 

 

 

sTReeT ADDRess

 

 

CiTy/Town

sTATe

 

ZiP CoDe +4

 

 

 

 

 

 

 

 

 

 

mAnufACTuReR’s legAl nAme

 

 

mAnufACTuReR’s CeRTifiCATe numbeR

TelePhone numbeR

 

 

 

 

 

M-

 

(

)

 

 

 

 

 

 

 

 

 

 

 

sTReeT ADDRess

 

 

CiTy/Town

sTATe

 

ZiP CoDe +4

 

 

 

 

 

 

 

 

 

 

ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY

14

PART 3 SMALL GAMES OF CHANCE CERTIFICATION

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 JuDiCiAlAPPeAl; 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 INASUPERVISORY 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.

IDECLARETHATIHAVEEXAMINEDTHISAPPLICATION,INCLUDINGALLACCOMPANYINGSTATEMENTS,ANDTOTHEBESTOFMYKNOWLEDGEANDBELIEFITISTRUE, CORRECT, AND COMPLETE.

 

NOTARY

AUTHORIZATION

 

 

 

 

 

 

 

 

 

 

 

swoRn AnD subsCRibeD To befoRe me This

 

 

 

 

 

 

_____________________ DAy of _________________ , 20____

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

signATuRe of An owneR, PARTneR, offiCeR,

soCiAl seCuRiTy numbeR

 

 

 

 

oR DiReCToR

 

 

 

 

 

 

 

 

 

 

 

noTARy PubliC

 

PRinT nAme

DATe

my Commission exPiRes

 

 

 

 

 

 

TiTle

 

 

 

 

 

 

 

 

 

 

()

TelePhone numbeR

noTARy seAl

CoRPoRATe seAl

 

15

PA-100 (TR) 03-18

 

DePARTmenT use only

 

 

enTeRPRise nAme

 

 

SECTION 21 – MOTOR CARRIER REGISTRATION & DECAL/MOTOR FUELS LICENSE & PERMIT

PART 1

VEHICLE OPERATIONS

 

 

 

 

 

 

 

 

 

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:

 

 

 

 

o Common CARRieR

o ConTRACT CARRieR

o foR hiRe CARRieR

o PRivATe CARRieR

o us DoT numbeR

 

inDiCATe The fuel TyPes foR PennsylvAniA bAseD QuAlifieD moToR vehiCles:

 

 

 

 

 

 

 

 

o Diesel

 

o gAsoline

o eThAnol/gAsohol

o lP gAs

o Cng/lng

 

.

.

o

o

yes

yes

o

o

no

hAve you eveR been issueD An inTeRnATionAl fuel TAx AgReemenT (ifTA) CReDenTiAl fRom AnoTheR JuRisDiCTion(s)?

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 $12.00 PER SET OF TWO.

1.IFTA DeCAls (numbeR of vehiCles ThAT TRAvel in PAAnD 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.

ToTAlAmounT Due (mulTiPly line 3 by $12.00)

$

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

COLUMN C

–

bulK sToRAge foR gAsoline is mAinTAineD

COLUMN D

–

bulK sToRAge of Any oTheR moToR fuel is mAinTAineD

A B C D

A B C D

o o o o AK – AlAsKA

o o o o iD – iDAho

o o o o Al – AlAbAmA

o o o o il – illinois

o o o o AR – ARKAnsAs

o o o o in – inDiAnA

o o o o AZ – ARiZonA

o o o o Ks – KAnsAs

o o o o CA – CAlifoRniA

o o o o Ky – KenTuCKy

o o o o Co – ColoRADo

o o o o lA – louisiAnA

o o o o CT – ConneCTiCuT

o o o o mA – mAssAChuseTTs

o o o o DC – DisT. of ColumbiA

o o o o mD – mARylAnD

o o o o De – DelAwARe

o o o o me – mAine

o o o o fl – floRiDA

o o o o mi – miChigAn

o o o o gA – geoRgiA

o o o o mn – minnesoTA

o o o o hi – hAwAii

o o o o mo – missouRi

o o o o iA – iowA

o o o o ms – mississiPPi

A B C D

o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o

mT – monTAnA

nC – noRTh CARolinA nD – noRTh DAKoTA ne – nebRAsKA

nh – new hAmPshiRe nJ – new JeRsey nm – new mexiCo nv – nevADA

ny – new yoRK oh – ohio oK – oKlAhomA oR – oRegon

PA – PennsylvAniA

A B C D

o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o

Ri –

RhoDe islAnD

sC –

souTh CARolinA

sD –

souTh DAKoTA

Tn –

Tennessee

Tx –

TexAs

uT –

uTAh

vA –

viRginiA

vT –

veRmonT

wA –

wAshingTon

wi –

wisConsin

wv –

wesT viRginiA

wy –

wyoming

A B C D

A B C D

o o o o Ab – AlbeRTA

o o o o nb – new bRunswiCK

o o o o bC – bRiTish ColumbiA

o o o o nf – newfounDlAnD

o o o o mb – mAniTobA

o o o o ns – novA sCoTiA

A B C D

A B C D

o o o o nT – n w TeRRiToRy

o o o o PQ – QuebeC

o o o o on – onTARio

o o o o sK – sAsKATChewAn

o o o o Pe – PRinCe eDwARD is.

o o o o yT - yuKon TeRRiToRy

PART 2

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.PA.GOV, foRms AnD PubliCATions, moToR fuel TAx.

16

PA-100 (TR) 03-18

 

DePARTmenT use only

 

 

enTeRPRise nAme

 

 

SECTION 22 – SALES TAX EXEMPT STATUS FOR CHARITABLE AND RELIGIOUS ORGANIZATIONS

PART 1

ACT 55 of 1997, KnownAs The insTiTuTions of PuRely PubliC ChARiTyACT, 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

PA-100 (TR) 03-18

SECTION 1 – REASON FOR THIS REGISTRATION

An enterprise may select more than one reason for registration.

1.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.

2.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.

3.Reactivating Tax(es) and Service(s): A registered enter- prise reactivating tax(es) and service(s) must complete sec- tions 1 through 6 and additional sections as appropriate.

4.Adding Establishment(s): A registered enterprise adding establishment location(s) must complete sections 1 through 6 and section 17, multiple establishment information.

5.Information Update: A registered enterprise providing changes in demographic or other information must com- plete sections 1 through 6 and additional sections as appropriate.

6.Did this Enterprise:

An enterprise acquiring the business of another enterprise in whole or in part must complete section 14, Predeces- sor/successor information. The business can be acquired by purchase, consolidation, merger, gift, or change in legal structure. A stock acquisition ALONE does not consti- tute a transfer of the business.

Check the appropriate box to indicate the business opera- tion 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 sec- tions 1 through 6, 10, 14 and additional sections as appropriate.

• An enterprise requesting the PA unemployment Com- pensation (uC) experience record and reserve account balance of a predecessor (prior owner) must also com- plete section 15, Application for PA uC experience Record and Reserve Account balance of Predecessor.

SECTION 2 – ENTERPRISE INFORMATION

1.Date of First Operations: enter the first date the enter- prise conducted any activity. This includes start-up opera- tions prior to opening for business.

2.Date of First Operations in PA: enter the first date the enterprise conducted any activity in PA or employed PA res- idents. This includes start-up operations prior to opening for business.

3.Enterprise Fiscal Year End: enter the month (January, february, etc.) used by the enterprise to designate the end of its accounting period.

4.Enterprise Legal Name: enter the legal name of the enterprise.

 

 

 

IF THE BUSINESS STRUCTURE IS:

USE THE:

 

sole PRoPRieToRshiP

inDiviDuAl owneR’s nAme.

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

nAme As shown in The

PRofessionAl ComPAny

ARTiCles of oRgAniZATion.

goveRnmenT

offiCiAl/legAl nAme of

 

The oRgAniZATion.

 

 

 

5.Federal EIN: enter the federal employer identification num- ber (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 enter- prise 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 num- ber 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 enter- prise 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.EstablishmentName:enter the name by which the establish- ment 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 establish- ments. 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 estab- lishment information.

18

13.PA School District: enter the school district where the estab- lishment is located. if not a PA school district, enter “n/A”.

14.PA Municipality: enter the municipality (borough, city, town, or township) where the establishment is located. The municipality may be different from the city/town used for postal delivery. if not a PA municipality, enter “n/A”.

SECTION 3 – TAXES AND SERVICES

indicate the tax(es) and service(s) requested. Descriptions, addi- tional requirements and sections to complete are on page(s) 2 and 3. enter the previous account number(s) when reactivat- ing tax(es) and service(s).

SECTION 4 – AUTHORIZED SIGNATURE

Authorized Signature: owner, general partner, officer, or agent signature is required. enter the title and daytime phone number of the person who signed the form. Attach Power of Attorney document, if applicable.

Type or Print Name: Type or print the name of the person who signed the document, enter their e-mail address, and the date it was signed.

Type or Print Name: Type or print the name of the preparer, the title of the person who prepared the form, if other than the owner, partner or officer. enter the preparer’s daytime telephone number, e-mail address, and the date the form was prepared.

SECTION 5 – BUSINESS STRUCTURE

1.Check the box to select the form of organization that applies to the enterprise.

• A sole proprietor is one individual owner and indicates 100 percent ownership.

• Two or more individuals listed as owners constitute a partnership and will be registered as one. Registrants for unemployment Compensation should attach a copy of the partnership agreement, if available.

• limited liability companies and restricted professional companies must enter the state/province where char- tered.

The following forms of organization require the completion of additional sections:

• Corporation - Complete section 11, Corporation infor- mation.

• government - Complete section 13, government infor- mation.

2.Check the box to indicate if the enterprise is profit or non- profit.

3.if an enterprise is exempt under section 501(c)(3) of the internal Revenue Code (iRC), and is also subject to the con- tribution provisions of the Pennsylvania unemployment Compensation (uC) law, it has the option to elect to finance uC costs under the reimbursement method in lieu of the contributory method.

see page 22 of the instructions for further explanations regard- ing contributory and reimbursement methods of making pay- ments to the unemployment Compensation fund.

SECTION 6 – OWNERS, PARTNERS, SHAREHOLDERS, OFFICERS,

AND RESPONSIBLE PARTY INFORMATION

identify and provide information on the following:

•The sole proprietor who is 100 percent owner. A sole proprietor must be one individual.

•All general partners and all limited partners who are involved in the daily operation of the business.

•All shareholders (both individuals and enterprises) own- ing stock. if the stock is publicly traded, identify any shareholder with an equity position of 5 percent or more.

•All officers of the corporation, association, or business trust.

•All individuals responsible for remitting trust fund taxes or maintaining workers’ Compensation Coverage.

1.Name: enter the name(s) of the owner, partner, sharehold- er, officer, or responsible party of the enterprise. if the owner is another enterprise, enter the legal name of the enterprise.

2.Social Security Number: enter the social security num- ber of the owner, partner, shareholder, officer, or respon- sible party.

3.Date of Birth: enter the individual’s date of birth if applying for a Cigarette wholesale Dealer’s license, a small games of Chance Distributor license, or manufacturer Certificate.

4.Federal EIN: enter the federal employer identification number (ein) if the owner, partner, or shareholder is another enterprise.

5.Type of Ownership/Position: Check the box(es) to desig- nate if an owner, partner, officer, shareholder, or responsi- ble party.

6-9. Title, Effective Dates, Percentage of Ownership: enter the title, effective dates, and percentage of ownership as indicated.

10.Home Address: enter the home street address of the owner, partner, shareholder, officer, or responsible party. if the owner, partner, or shareholder is another enterprise, enter the street address of the enterprise. A post office box is not acceptable.

11.Person Responsible to Remit/Maintain: Check the appropriate box(es) to indicate the Taxes/services for which this individual is responsible.

Responsible Party: Please identify the person(s) responsible for remitting sales Tax, employer withholding Tax, liquid fuels and fuels Taxes, or maintaining workers’ Compensation Coverage. under PAlaw, a proprietor, a general partner, a corporation’s chief operating officer(s), and/or a chief financial officer is responsible for ensuring that collected trust fund taxes are remitted on a timely basis and workers’ compensation coverage is maintained when required. other individuals may also be responsible if their duties, position, or authority over financial matters and decision-making put them in a position to influence the payment of these taxes or maintaining business operation. failure to remit these taxes in a timely manner or to maintain ongoing workers’ compensation cov- erage when required may result in the personal assessment of a responsible party, together with the possibility of criminal sanc- tions, if warranted.

space for additional information of owners, partners, sharehold- ers, officers, and/or responsible parties can be found on page 11. Attach additional 8 1/2 x 11 sheets if necessary.

19

SECTION 7 – ESTABLISHMENT BUSINESS ACTIVITY INFORMATION

ENTER THE PERCENTAGE THAT EACH PABUSINESSACTIVITYREPRESENTS OF THE TOTAL RECEIPTS OR REVENUES AT THISESTABLISHMENT. LIST PRODUCTS OR SERVICESASSOCIATED WITH EACH BUSINESS ACTIVITY AND THE PERCENTAGE REPRESENTING THE TOTAL RECEIPTS OR REVENUES.

E X A M P L E

PA BUSINESS ACTIVITY

%

PRODUCTS OR SERVICES

%

ADDITIONAL PRODUCTS OR SERVICES

%

 

CONSTRUCTION

70

BUILDING SINGLE FAMILY HOMES

40

BUILDING APARTMENT BUILDINGS

30

 

MANUFACTURING

 

 

 

 

 

 

RETAIL TRADE

 

 

 

 

 

 

WHOLESALE TRADE

30

WOOD PANELING

30

 

 

 

 

 

 

 

 

 

 

PA BUSINESS ACTIVITIES AND TYPICAL PRODUCTS OR SERVICES EXAMPLES.

THIS SECTION IS NOT FOR DETERMINING THE TAXABILITY OF PRODUCTS OR SERVICES, ONLY THE CLASSIFICATION OF PRODUCTS AND SERVICES.

PA BUSINESS ACTIVITY

 

TYPICAL PRODUCTS OR SERVICES

 

 

 

 

 

 

ACCOMMODATION AND FOOD SERVICES

 

SPECIFY THE TYPE OF FACILITY WHERE ACTIVITY TAKES PLACE. FOR EXAMPLE:

 

 

 

 

ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR PROVIDE CUSTOMERS

HOTELS

RV PARKS AND CAMP-

FULL/LIMITED SERVICE

MOTELS

GROUNDS

RESTAURANTS

WITH LODGING AND/OR PREPARE MEALS, SNACKS, AND BEVERAGES FOR IMMEDI-

 

 

 

VACATION CAMPS

MOBILE FOOD SERVICES

ATE CONSUMPTION.

 

 

 

 

 

 

 

 

 

 

 

AND CATERERS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SPECIFY THE TYPE OF CROP GROWN, LIVESTOCK RAISED, FISH CAUGHT, AND FORESTRY WORK.

 

 

 

 

 

FOR EXAMPLE:

 

 

AGRICULTURE, FORESTRY, FISHING, AND HUNTING

CROPS (CORN, WHEAT, APPLE)

DAIRY CATTLE AND MILK PRO-

HUNTING AND TRAPPING

ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE INVOLVED IN

AND WHETHER UNDER COVER

DUCTION

SUPPORT ACTIVITIES FOR

 

 

GROWING CROPS, RAISING ANIMALS, HARVESTING FISH AND OTHER ANIMALS FROM

NURSERY/TREE

CHICKEN (EGG OR MEAT

CROP PRODUCTION/

FARMS, RANCHES, OR ANIMALS' NATURAL HABITATS.

 

 

TYPE)

FORESTRY (AERIAL DUSTING,

 

 

PRODUCTIONS

 

CULTIVATING SERVICES,

 

 

 

 

 

TIMBER TRACTS, LOGGING

 

 

 

 

 

 

FOREST FIRE FIGHTING,

 

 

 

 

 

 

 

 

 

 

 

 

CATTLE RANCHING

COMMERCIAL FISHING

PEST CONTROL)

 

 

 

 

 

 

 

 

 

 

 

SPECIFY THE TYPE OF ART, ENTERTAINMENT, AND/OR RECREATION PROVIDED. FOR EXAMPLE:

ART, ENTERTAINMENT, AND RECREATION SERVICES

THEATER COMPANIES

RACETRACKS

AMUSEMENT AND THEME

 

 

 

 

 

ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE OPERATING OR

DANCE COMPANIES

AGENTS AND MANAGERS

PARKS

PROVIDING SERVICES TO MEET VARIED CULTURAL, ENTERTAINMENT, AND RECRE-

MUSICAL GROUPS AND

INDEPENDENT ARTISTS,

RIDING STABLES

ATIONAL INTERESTS OF THEIR PATRONS.

 

 

 

 

 

 

 

 

ARTISTS

WRITERS, AND PERFORMERS

 

 

 

 

 

 

 

 

 

 

SPORTS TEAMS AND CLUBS

CASINOS

 

 

 

 

 

 

COMMUNICATIONS/INFORMATION

 

 

 

SPECIFY THE TYPE OF COMMUNICATION/INFORMATION ACTIVITY PERFORMED. FOR EXAMPLE:

ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE DISTRIBUTING

PUBLISHING

RADIO/TELEVISION BROAD-

PAGING

(NEWSPAPER, DATABASE,

CASTING

 

INFORMATION AND CULTURAL PRODUCTS, PROVIDING THE MEANS TO TRANSMIT

ON-LINE INFORMATION

SOFTWARE)

CABLE

OR DISTRIBUTE THESE PRODUCTS AS DATA OR COMMUNICATIONS, AND PRO-

SERVICES

MOTION PICTURE/VIDEO PRO-

WIRED/WIRELESS TELECOM-

 

 

 

 

 

CESSING DATA.

 

 

 

 

 

 

 

 

 

DUCTION

MUNICATIONS

LIBRARIES AND ARCHIVES

 

 

 

 

 

 

 

 

 

 

 

 

CONSTRUCTION

 

 

 

 

SPECIFY THE TYPE OF CONSTRUCTION. FOR EXAMPLE:

 

ESTABLISHMENTS ENGAGED IN ACTIVITIES

OF

THIS

SECTOR ARE

PRIMARILY

GENERAL OR OPERATIVE

INDUSTRIAL

ELECTRIC

ENGAGED IN THE CONSTRUCTION OF BUILDINGS OR ENGINEERING PROJECTS (E.G.

BUILDERS (RESIDENTIAL OR

 

 

HIGHWAYS AND UTILITY SYSTEMS) INCLUDING SITE PREPARATION FOR NEW CON-

HEAVY (BRIDGES, HIGHWAYS,

 

NONRESIDENTIAL)

EXCAVATION

STRUCTION AND SUBDIVIDING LAND FOR SALE AS BUILDING SITES. ACTIVITIES MAY

STREETS)

 

INCLUDE RESIDENTIAL/COMMERCIAL NEW WORK, ADDITIONS, ALTERATIONS, OR MAIN-

 

 

 

TENANCE AND REPAIRS.

 

 

 

 

COMMERCIAL

PLUMBING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOMESTICS

 

 

 

 

SPECIFY THE TYPE OF SERVICE. FOR EXAMPLE:

 

ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE COMPRISED OF

COOKS

NANNIES

GARDENERS

PRIVATE HOUSEHOLDS ENGAGED IN EMPLOYING WORKERS ON OR ABOUT THE

MAIDS

BUTLERS

CARETAKERS, AND OTHER

PREMISES IN ACTIVITIES PRIMARILY CONCERNED WITH THE OPERATION OF THE

HOUSEHOLD.

 

 

 

 

 

 

MAINTENANCE WORKERS

 

 

 

 

 

 

 

 

 

 

 

 

SPECIFY THE TYPE OF TRAINING FACILITY. FOR EXAMPLE:

 

EDUCATIONAL SERVICES

 

 

 

 

SCHOOLS

BUSINESS/SECRETARIAL

TRADE, APPRENTICESHIP,

 

 

 

 

 

ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE PROVIDING

COLLEGES

SCHOOLS

COSMETOLOGY AND BARBER

INSTRUCTION AND TRAINING IN A WIDE VARIETY OF SUBJECTS.

 

 

SCHOOLS)

 

UNIVERSITIES

TRAINING CENTERS (COMPUT-

 

 

 

 

 

ER, FLIGHT, TECHNICAL AND

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FINANCE

 

 

 

 

SPECIFY THE TYPE OF FINANCIAL INSTITUTION, CHARTER, AND TYPE OF FINANCIAL PRODUCTS AND

ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR INVOLVE THE CRE-

SERVICES OFFERED. FOR EXAMPLE:

 

 

 

 

ATION, LIQUIDATION, OR CHANGE IN OWNERSHIP OF FINANCIAL ASSETS (FINANCIAL

COMMERCIAL BANKS

SALES FINANCING

INVESTMENT BANKING AND

 

 

SECURITIES DEALING

TRANSACTIONS) AND/OR FACILITATING FINANCIAL TRANSACTIONS.

 

CREDIT UNIONS

REAL ESTATE LENDING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SPECIFY THE TYPE OF SERVICE PERFORMED. FOR EXAMPLE:

 

HEALTH CARE SERVICES

 

 

 

 

AMBULATORY HEALTH CARE

MENTAL HEALTH

KIDNEY DIALYSIS CENTERS

ESTABLISHMENTS ENGAGED IN ACTIVITIES

OF

THIS

SECTOR ARE

PROVIDING

PHYSICIANS

PRACTITIONERS

MEDICAL AND DIAGNOSTIC

PODIATRISTS

LABORATORIES

HEALTH CARE FOR INDIVIDUALS.

 

 

 

 

DENTISTS

 

 

 

 

OUTPATIENT CARE CENTERS

HOME HEALTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OPTOMETRISTS

HMO MEDICAL CENTERS

CARE SERVICES

 

 

 

 

 

 

INSURANCE

 

 

 

 

SPECIFY THE TYPE OF INSURANCE SOLD, AND SPECIFY IF THE INSURANCE IS UNDERWRITTEN BY

ESTABLISHMENTS ENGAGED IN ACTIVITIES

OF

THIS

SECTOR ARE

PRIMARILY

THE SAME ENTERPRISE. FOR EXAMPLE:

 

DIRECT LIFE

PROPERTY AND CASUALTY

CLAIMS ADJUSTING

ENGAGED IN UNDERWRITING ANNUITIES AND INSURANCE POLICIES, OR FACILITAT-

 

 

 

ING SUCH UNDERWRITING BY SELLING INSURANCE POLICIES, AND BY PROVIDING

HEALTH AND MEDICAL

TITLE

FUNDS AND TRUSTS

OTHER INSURANCE AND EMPLOYEE-BENEFIT RELATED SERVICES.

 

INSURANCE CARRIERS

REINSURANCE

 

 

 

 

 

 

 

 

 

MANAGEMENT, SUPPORT AND REMEDIATION SERVICES

SPECIFY TYPE OF OFFICE, SUPPORT OR REMEDIATION SERVICES. FOR EXAMPLE:

ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE PERFORMING

CALL CENTERS

LANDSCAPE SERVICES

HOLDING COMPANIES

ROUTINE SUPPORT ACTIVITIES FOR THE DAY-TO-DAY OPERATIONS OF OTHER

 

 

 

ORGANIZATIONS. THE ADMINISTRATIVE AND MANAGEMENT ACTIVITIES PER-

TEMPORARY HELP

TRAVEL AGENCIES

CREDIT BUREAU

FORMED ARE TYPICALLY ON A CONTRACT OR FEE BASIS. ALTHOUGH THESE ACTIV-

 

 

 

 

CORPORATE OFFICE

ITIES MAY ALSO BE PERFORMED BY ESTABLISHMENTS THAT ARE PART OF THE

PROFESSIONAL EMPLOYEE

WASTE COLLECTIONS AND

 

COMPANY OR ENTERPRISE.

 

 

 

 

ORGANIZATION

DISPOSAL

JANITORIAL SERVICES

 

 

 

 

 

20

PA BUSINESS ACTIVITY

TYPICAL PRODUCTS OR SERVICES

 

SPECIFY THE PRODUCTS MANUFACTURED AND/OR TYPE OF PLANT & PRINCIPAL PROCESS USED.

 

FOR EXAMPLE:

 

 

MANUFACTURING

FOOD (FROZEN OR UNFROZEN,

WOOD PRODUCTS (PALLETS,

FLEXOGRAPHIC, GRAVURE,

 

ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE INVOLVED IN THE

CANNED)

DOORS, WINDOWS)

QUICK, SCREEN, OR DIGITAL)

 

 

MECHANICAL, PHYSICAL, OR CHEMICAL TRANSFORMATION OF MATERIAL, SUBSTANCES,

TEXTILES

PULP, PAPER, AND PAPER-

CHEMICAL

OR COMPONENTS INTO NEW PRODUCTS.

METAL (FERROUS, NONFER-

 

BOARD

 

CLOTHING/FOOTWEAR (MEN’S,

 

ROUS, FABRICATED, FORGED,

 

 

 

 

 

 

BOY’S, WOMEN’S, GIRL’S)

PRINTING (LITHOGRAPH

OR STAMPED)

 

 

MINING, QUARRYING, OIL/GAS EXTRACTION

SPECIFY EACH MINERAL OR PRODUCT EXTRACTED, IF SERVICES, DESCRIBE SERVICE AND MINERAL

INVOLVED. FOR EXAMPLE:

 

 

ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE EXTRACTING NATU-

OPERATING AND/OR DEVELOP-

ANTHRACITE COAL MINING

SUPPORT ACTIVITY, EXCAVAT-

RALLY OCCURRING MINERAL SOLIDS, SUCH AS COAL AND ORE; LIQUID MINERALS, SUCH

ING OIL AND GAS FIELDS OR

(SURFACE OR UNDERGROUND)

ING SLUSH PITS, GEOLOGICAL

AS CRUDE PETROLEUM; AND GASES, SUCH AS NATURAL GAS. THE TERM MINING IS

CRUDE PETROLEUM AND NAT-

 

OBSERVATIONS, GRADING AND

USED IN THE BROAD SENSE TO INCLUDE QUARRYING, WELL OPERATIONS, BENEFICIAT-

METAL/NON- METAL ORES

URAL GAS EXTRACTION

BUILDING FOUNDATIONS AT

ING (E.G., CRUSHING, SCREENING, WASHING, AND FLOTATION), AND OTHER PREPARA-

EXPLORATION FOR CRUDE

GOLD, SILVER, STONE, SAND,

WELL LOCATIONS

TION CUSTOMARILY PERFORMED AT THE MINE SITE, OR AS PART OF MINING ACTIVITY.

REFRACTORY

PETROLEUM, BITUMINOUS, OR

 

 

 

 

 

 

 

OTHER SERVICES (EXCEPT PUBLIC ADMINISTRATION)

SPECIFY THE TYPE OF SERVICE PROVIDED. FOR EXAMPLE:

 

ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE PROVIDING SER-

AUTOMOTIVE

COMMUNICATION

BARBER

 

VICES NOT ELSEWHERE SPECIFIED, INCLUDING REPAIRS, RELIGIOUS ACTIVITIES,

ELECTRONIC

COMMERCIAL AND

BEAUTY AND NAIL SALONS

GRANT MAKING, ADVOCACY, LAUNDRY, PERSONAL CARE, DEATH CARE, AND OTHER

INDUSTRIAL MACHINERY

PET CARE (GROOMING, AND/OR

 

PERSONAL SERVICES.

 

COMPUTER

REPAIRS

BOARDING)

 

 

 

 

 

SPECIFY THE TYPE OF SERVICE PROVIDED. FOR EXAMPLE:

 

PROFESSIONAL, SCIENTIFIC, AND TECHNICAL SERVICES

LEGAL ADVICE AND REPRESEN-

ARCHITECTURAL

ADVERTISING

ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE PERFORMING PROFES-

TATION

ENGINEERING

PHOTOGRAPHIC

SIONAL, SCIENTIFIC, AND TECHNICAL SERVICES FOR THE OPERATIONS OF OTHER

ACCOUNTING

COMPUTER SERVICES

TRANSLATION AND INTERPRE-

ORGANIZATIONS.

BOOKKEEPING

CONSULTING

TATION

 

 

PAYROLL SERVICES

RESEARCH

VETERINARY SERVICES

 

 

 

 

PUBLIC ADMINISTRATION

SPECIFY OFFICE. FOR EXAMPLE:

 

 

EXECUTIVE OFFICES OF PRESI-

ZONING BOARDS AND COMMIS-

CIVILIAN COURTS OF LAW

 

ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE ADMINISTRATION,

DENT

SIONS ( PUBLIC

 

MANAGEMENT, AND OVERSIGHT OF PUBLIC PROGRAMS BY FEDERAL, STATE, AND LOCAL

GOVERNORS AND MAYORS IN

ADMINISTRATION)

COURTS OF LAW AND

GOVERNMENTS.

ADDITION TO EXECUTIVE

GOVERNMENT URBAN

SHERIFFS OFFICES CONDUCT-

 

ADVISORY COMMISSIONS

PLANNING COMMISSIONS

ING COURT FUNCTIONS ONLY

 

 

 

REAL ESTATE

SPECIFY THE TYPE OF REAL ESTATE ACTIVITY. FOR EXAMPLE:

 

 

 

 

ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE RENTING, LEASING,

SELF-STORAGE RENTAL, REAL

CONSUMER GOODS

PATENTS

ESTATE

 

TRADEMARKS

OR OTHERWISE ALLOWING THE USE OF TANGIBLE OR INTANGIBLE ASSETS (EXCEPT

COMMERCIAL AND

AGENTS/BROKERS

COPYRIGHTED WORKS), AND PROVIDING RELATED SERVICES.

INDUSTRIAL

BRAND NAMES, AND/OR FRAN-

 

 

CAR RENTAL/LEASING

MACHINERY/EQUIPMENT

CHISE AGREEMENT

 

 

 

RETAIL TRADE

SPECIFY THE DIFFERENT TYPES OF RETAIL STORES. FOR EXAMPLE:

 

ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR RETAIL MERCHANDISE,

DEPARTMENT STORES

CLOTHING AND GROCERY

VENDING MACHINES AND

GENERALLY IN SMALL QUANTITIES, TO THE GENERAL PUBLIC, AND PROVIDE SERVICES

FURNITURE STORES

IN-HOME DEMONSTRATION,

STREET VENDORS

INCIDENTAL TO THE SALE OF THE MERCHANDISE.

 

INFOMERCIALS

(EXCEPT FOOD)

 

 

 

 

 

SANITARY SERVICE

SPECIFY THE TYPE OF SERVICE PROVIDED. FOR EXAMPLE:

 

 

 

 

ESTABLISHMENTS ENGAGED IN ACTIVITIES IN THIS SECTOR ARE INVOLVED IN THE COL-

LOCAL HAULING OF WASTE

SEPTIC PUMPING

SOLID WASTE LANDFILLS

MATERIALS

HAZARDOUS AND

 

LECTION, TREATMENT, AND DISPOSAL OF WASTE MATERIALS NOT THROUGH SEWER

COMBUSTORS AND

 

SYSTEMS OR SEWAGE TREATMENT FACILITIES.

REMEDIATION SERVICES

NON-HAZARDOUS WASTE

INCINERATORS

 

 

TRANSFER STATIONS

 

 

 

 

SOCIAL ASSISTANCE SERVICE

SPECIFY THE TYPE OF SERVICE PROVIDED. FOR EXAMPLE:

 

ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR PROVIDE A WIDE VARI-

YOUTH CENTERS

TEMPORARY SHELTERS

CHILD DAY CARE

ETY OF SOCIAL ASSISTANCE SERVICES DIRECTLY TO THEIR CLIENTS. THESE SER-

ADOPTION AGENCIES

SERVICES FOR ELDERLY AND

 

VICES DO NOT INCLUDE RESIDENTIAL OR ACCOMMODATION SERVICES, EXCEPT ON A

 

 

PERSONS WITH DISABILITIES

 

SHORT STAY BASIS.

 

 

 

 

 

 

 

 

TRANSPORTATION

SPECIFY THE TYPE OF TRANSPORTATION MODE. FOR EXAMPLE:

 

AIR (SPECIFY SCHEDULED OR

GREAT LAKES

BUS

ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR PROVIDE TRANSPORTA-

NONSCHEDULED; PASSENGER

TRUCKING (GENERAL OR SPE-

TAXI

TION OF PASSENGERS AND CARGO, SCENIC AND SIGHTSEEING TRANSPORTATION,

OR FREIGHT)

SCHOOL BUS

AND SUPPORT ACTIVITIES RELATED TO MODES OF TRANSPORTATION.

CIALIZED LONG-DISTANCE OR

 

RAIL, DEEP SEA, COASTAL, AND

LOCAL)

LIMOUSINE

 

 

 

UTILITIES

SPECIFY THE TYPE OF SERVICE. FOR EXAMPLE:

 

ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR PROVIDE ELECTRIC

ELECTRIC

TRANSMISSION

SEWAGE TREATMENT

POWER, NATURAL GAS, STEAM SUPPLY, WATER SUPPLY, AND SEWAGE REMOVAL. THE

 

 

FACILITIES

SPECIFIC ACTIVITIES ASSOCIATED WITH THE UTILITY SERVICES PROVIDED VARY BY

HYDROELECTRIC

DISTRIBUTION

 

UTILITY: ELECTRIC POWER INCLUDES GENERATION, TRANSMISSION, AND DISTRIBU-

NUCLEAR

WATER TREATMENT AND/OR

 

TION; NATURAL GAS INCLUDES DISTRIBUTION; STEAM SUPPLY INCLUDES PROVISION

 

AND/OR DISTRIBUTION; WATER SUPPLY INCLUDES TREATMENT AND DISTRIBUTION;

FOSSIL FUEL

WATER SUPPLY SYSTEMS

 

AND SEWAGE REMOVAL INCLUDES COLLECTION, TREATMENT, AND DISPOSAL OF

 

 

 

 

 

WASTE THROUGH SEWER SYSTEMS AND SEWAGE TREATMENT FACILITIES.

 

 

 

 

 

 

WAREHOUSING

SPECIFY THE TYPE OF STORAGE. FOR EXAMPLE:

 

ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE PRIMARILY ENGAGED

GENERAL WAREHOUSING

REFRIGERATED

EXCLUDED ARE RENTING AND

IN OPERATING WAREHOUSING AND STORAGE FACILITIES FOR GENERAL MERCHAN-

 

FARM PRODUCTS

LEASING SPACE FOR SELF-

DISE, REFRIGERATED GOODS, AND OTHER WAREHOUSE PRODUCTS, WHICH MAY

 

 

 

STORAGE – SEE REAL ESTATE

INCLUDE LOGISTICS.

 

 

 

 

 

 

 

 

WHOLESALE TRADE

SPECIFY THE DIFFERENT TYPES OF TRADERS. FOR EXAMPLE:

 

ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR COMPRISE TWO MAIN

MERCHANT WHOLESALERS

BUSINESS TO BUSINESS ELEC-

AGENTS, AND BROKERS

TYPES OF ENTERPRISES SELLING OR ARRANGING FOR THE PURCHASE OR SALE OF

(DISTRIBUTORS, JOBBERS,

TRONIC MARKETS

ARRANGING SALES AND PUR-

GOODS FOR RESALE; CAPITAL OR DURABLE NON-CONSUMER GOODS; AND RAW AND

DROP SHIPPERS, AND

 

CHASES FOR OTHERS ON A

INTERMEDIATE MATERIALS AND SUPPLIES USED IN PRODUCTION, AND PROVIDING

 

IMPORT/EXPORT MERCHANTS)

 

FEE OR COMMISSION BASIS

SERVICES INCIDENTAL TO THE SALE OF THE MERCHANDISE.

 

 

 

 

 

2.Percentage: Enter the percentage that this ESTABLISHMENT’S receipts or revenues represent of the total PA receipts or revenues of the enterprise.

3.Establishments involved in construction business activity must enter the percentages of each type; residential and/or commercial; new and/or renovative. Each set of percent- age types should equal 100 percent of the construction activity at this establishment.

4.Check the appropriate box. If yes, a representative of the PA Lottery will call or visit the enterprise to answer questions and explain how to become a licensed Lottery Retailer.

21

SECTION 8 – ESTABLISHMENT SALES INFORMATION

1.Check the appropriate box to indicate if the establishment is selling products or services subject to sales Tax in PA. Prod- ucts and services include the sale and/or repair to tangible personal property, prepared food, rental and leasing of motor vehicles, and rental and leasing of equipment. Com- plete section 18 to apply for a PA sales Tax license.

2.Check the appropriate box to indicate if the establishment is selling cigarettes in PA. Complete section 18 to apply for a sales Tax license and section 19 to apply for a Cig- arette Tax license.

3.list each county in PA where taxable sales and/or ser- vices are offered or supplied.

SECTION 9 – ESTABLISHMENT EMPLOYMENT INFORMATION

PART 1

1.a – g Complete if the establishment employs individuals working in PA. if the principal business activity is not construction, enter “n/A” in items d and e.

Check the appropriate box in g-3 if the establishment is not required to have workers’ compensation coverage and pro- vide bureau code.

2.a – c Complete if the establishment employs PA residents working outside of PA.

3.Check the appropriate box. if yes, explain the services per- formed and why you do not consider the individual(s) to be employee(s).

4.Any payor/lessee required to withhold must apply for a 1099-misC withholding account by completing a PA-100 Pennsylvania enterprise Registration form. if you already have an employer withholding account and you do not want to report the 1099-misC separately, you do not have to complete a new registration. however, if you want to report the 1099-misC separately, you must register for a 1099- misC withholding account.

PART 2

1.a – b Complete if registering for withholding on taxable benefits paid from a benefit trust, deferred payment, or retirement plan for PA residents.

SECTION 10 – BULK SALE/TRANSFER INFORMATION

A separate copy of section 10 must be completed for each trans- feror from which assets were acquired.

Assets include, but are not limited to, any stock of goods, wares, or merchandise of any kind, fixtures, machinery, equipment, buildings or real estate, name and/or goodwill. Refer to the form for the class of assets.

1.indicate if the enterprise has acquired “in bulK” 51 percent or more of any class of PA assets of another enterprise.

2.indicate if the enterprise has acquired “in bulK” 51 percent or more of the total assets of another enterprise.

3-7. Complete if the answer to question 1 or 2 is “yes”.

To obtain a bulk sale Clearance Certificate, the seller must com- plete the Application for Tax Clearance Certificate, Rev-181. Pursuant to 72 P. s. § 1403 failure of the purchaser to require this certificate shall render such purchaser liable to the Commonwealth for the unpaid debts owing by the seller or trans- feror to and including the date of such transfer, whether or not at the time such debts have been settled, assessed, or determined.

SECTION 11 – CORPORATION INFORMATION

All corporations must register with the PA Department of State to secure corporate name clearance and register for corporation tax purposes. To register a new corporation via the Internet or to download the necessary forms, visit www.paopenforbusiness.state.pa.us, or call the PA Depart- ment of State at (717) 787-1057.

1-6. Describe the corporation.

7.Check the box if the corporation is a federal “s” corpora- tion. in accordance with Act no. 67 of 2006, a Corpora- tion with federal sub-Chapter s status is considered a PA s Corporation. in order not to be taxed as a PA s Corpo- ration, Rev-976 must be filed. To obtain this form on-line visit www.revenue.state.pa.us, or call the PA Depart- ment of Revenue at (717) 787-1064.

SECTION 12 – REPORTING & PAYMENT METHODS

1.Payments equal to or greater than $20,000 to the Depart- ment of Revenue must be remitted via an approved efT method. if a payment of $20,000 or more is not made via an approved efT method, the account is subject to a $500.00 penalty. Taxpayers must register with the PA Department of Revenue to remit payments via efT.

An enterprise may also participate voluntarily in the Depart- ment of Revenue’s efT Program.

2.The unemployment Compensation Contribution methods are: Contributory Method: under the contributory method, the amount of employer contributions due is based on a specified percentage of taxable wages. The maximum amount of taxable wages subject to the employer contribu- tion may change from year to year.

For-profit enterprises must pay under the contributory method.

Reimbursement Method: non-profit enterprises exempt under section 501(c)(3) of the internal Revenue Code and political subdivisions of PA who elect the reimbursement method are required to reimburse the uC fund for all regular benefits paid which are attributable to service with the enter- prise.

An enterprise will be assigned the contributory method of payment unless an election for reimbursement coverage is filed and approved by the PADepartment of labor & industry.

UC Employee Withholding Contributions: enterprises are required to report gross wages paid to employees, regardless of the method used to finance uC costs (contrib- utory or reimbursement). enterprises may be required to withhold and remit employee contributions according to section 301.4(a) of the PA uC law. The amount of employee contributions due is based on a specified per- centage of gross wages. employee contributions are not credited to an enterprise’s reserve account balance, nor are they considered to be contributions for federal certifica- tion purposes under the federal unemployment Tax Act.

Additional information is available by contacting the near- est Department of labor & industry field Accounting ser- vice office.

Magnetic Media Filing for UC: enterprises with 250 or more wage entries are required to report quarterly unem- ployment Compensation wages to the Department of labor & industry via magnetic media. non-compliance may result in penalty charges. Any magnetic reporting file must be submitted for compatibility with the Department of labor & industry’s format.

Electronic Filing: The Commonwealth’s electronic Tax information and Data exchange system (e-TiDes) is an

22

internet based filing and payment system that can be used to simplify reporting requirements for unemployment Com- pensation, employer withholding Tax and sales and use Tax. using e-TiDes will help your enterprise reduce the costs and delays associated with processing paper tax returns. To learn more about e-TiDes, visit the web site at www.etides.state.pa.us.

SECTION 13 – GOVERNMENT STRUCTURE

Complete this section if the enterprise is a political subdivision of the Commonwealth of PA, or if the enterprise exercises political authority as a government organization.

1.Check the appropriate box to describe the enterprise.

2.Check the appropriate box to further describe the type of government.

3.if the enterprise is a Domestic/usA form of government, check the appropriate box.

if an enterprise is a political subdivision of the Commonwealth of PA and is also subject to the contribution provisions of the PA unemployment Compensation (uC) law, it has the option to elect to finance uC costs under the reimbursement method in lieu of the contributory method. A state government organiza- tion will be assigned the reimbursement method.

see page 22 of the instructions for further explanations regard- ing contributory and reimbursement methods of making pay- ments to the unemployment Compensation fund.

SECTION 14 – PREDECESSOR/SUCCESSOR INFORMATION

Complete this section if the registering enterprise is succeed- ing a predecessor (prior owner) in whole or in part. for assis- tance in completing sections 14, 15, and 16, contact the nearest Department of labor & industry field Accounting ser- vice office.

Predecessor: An enterprise that transfers all or part of its orga- nization, trade, business or workforce to another enterprise.

Successor: An enterprise that acquires by transfer all or part of the organization, trade, business or workforce from another enterprise.

The registering enterprise may apply for the unemployment Com- pensation (uC) experience record and reserve account balance of the predecessor by completing section 15, Application for PA uC experience Record & Reserve Account balance of Predeces- sor.

The Department of labor & industry may determine that a trans- fer of experience from a predecessor to the registering enter- prise will be mandatory provided there is common ownership, management or control, either directly or indirectly between the predecessor and the registering enterprise.

1-5. Provide predecessor information as requested on the form.

6.Check the appropriate box to indicate how the predeces- sor‘s business was acquired.

Purchase: occurs when a new owner purchases all or part of the enterprise, or its assets, excluding stock purchases.

Change in Legal Structure: occurs when the form of organization changes; for example, when a sole proprietor- ship incorporates, or forms a partnership.

Consolidation: occurs when a new corporation is formed by combining two or more corporations which then cease to exist.

Gift: occurs when the title to the property is transferred without consideration.

Merger: occurs when one corporation is absorbed by another. one corporation preserves its original charter or identity and continues to exist and the other corporate exis- tence terminates.

IRC Section 338 Election: occurs when a stock purchase is treated as an asset purchase under the internal Revenue Code section 338.

7.enter the date the business was acquired.

8.enter the percentage of the predecessor‘s total business acquired. Total business is defined as all activities reportable under a single federal employer identification number (ein) including any activities occurring outside of PA.

9.enter the percentage of the predecessor’s PA business acquired. if less than 100 percent, provide the additional information as requested on the form.

10.Describe the PA business activity(ies) that the registering enterprise acquired from the predecessor.

11.Check the appropriate box(es) to indicate the type(s) of assets acquired from the predecessor.

12.enter the date the predecessor last paid wages in PA, if applicable.

13.enter the date the predecessor ceased operations in PA, if applicable. if operations have not ceased, describe the predecessor‘s ongoing business activity in PA.

14.Check the appropriate box(es). if “yes”, provide the infor- mation requested on the form. Attach additional sheets if necessary.

SECTION 15 – APPLICATION FOR PA UC EXPERIENCE RECORD &

RESERVE ACCOUNT BALANCE OF PREDECESSOR

if the registering enterprise is continuing essentially the same business activity as the predecessor, 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, provided that:

•The registering enterprise is continuing essentially the same business activity as the predecessor;

•The business transfer, acquisition or merger was not under- taken solely or primarily to obtain a lower uC contribution rate, and;

•The registering enterprise’s risk of unemployment is related to the employment experience of the predecessor based upon the following factors:

• nature of the business activity of each enterprise • number of individuals employed by each enterprise • wages paid to the employees by each enterprise

it is important to consider more than the predecessor’s existing rate. The benefit charges attributed to the business acquired from the predecessor may have an adverse effect on future rate calculations.

The basic contribution rate for a newly liable non-construction employer is 3.5 percent (.0350). The basic contribution rate for newly liable employers involved in the performance of a contract or sub-contract for the construction of new roads, bridges, high- ways, buildings, factories, housing developments, or other con- struction projects is 9.7 percent (.0970).

for any given calendar year, newly liable contribution rates are subject to a positive or negative surcharge according to sec- tions 301.5 and 301.7 of the PA uC law.

To be considered timely, an Application for the Transfer of the experience Record & Reserve Account balance of a Prede- cessor must be filed prior to the end of the calendar year immediately following the year in which the transfer occurred.

23

1-2. Complete only to apply for the predecessor‘s experience record and reserve account balance. The authorized sig- nature should be that of the owner, general partner, or offi- cer of the predecessor and the registering enterprise. Attach Power of Attorney document, if applicable. if the predecessor‘s signature is unavailable, contact the nearest Department of labor & industry field Accounting service office for additional information.

SECTION 16 – UNEMPLOYMENT COMPENSATION PARTIAL

TRANSFER INFORMATION

Complete this section if the registering enterprise acquired only part of the predecessor’s PA business and is making application for the transfer of a portion of the predecessor’s experience record and reserve account balance.

Contact the nearest Department of labor & industry field Accounting service office for Replacement uC-2A for Partial Transfer (form uC-252) or for more information on the unem- ployment Compensation (uC) taxable wage base for a specific year. Refer to page 27 for a list of offices.

if the Department of labor & industry determines that a transfer of experience is mandatory, the registering enterprise will be required to complete this section and form uC-252.

1.enter the exact date wages were first paid in the part of the predecessor’s PA business or workforce that was transferred. This date must include any wages paid by known pre-predecessors; that is, any previous owners of the part transferred who had transferred their experience and reserve account balance to any successors, the last of which would be the current predecessor.

2.for each calendar quarter in the table, enter the number of employees who earned taxable wages in the part of the predecessor’s PA business or workforce that was transferred. include any quarters applicable to known pre- predecessors. enter zero for any quarter in which no employees earned taxable wages in the part of the busi- ness that was transferred.

3.for each calendar quarter in the table, enter the number of employees who earned taxable wages in the part of the predecessor’s entire PA business. include any quar- ters applicable to known pre-predecessor’s. enter zero for any quarter in which no employees earned taxable wages in the part of the business that was retained.

4.Complete item 4 only if the part of the business that was transferred was in existence for less than three full cal- endar years prior to the year of transfer. in item A, enter the number of employees who earned taxable wages in the part of the business that was transferred during the period from the first day of the quarter of transfer to the date of transfer. in item b, enter the number of employ- ees who earned taxable wages in the predecessor’s entire business during the period from the first day of the quarter of transfer to the date of transfer.

5.enter the total amount of taxable wages applicable to the predecessor’s entire PA business for the period from the beginning of the quarter of transfer to the actual date of transfer.

SECTION 17 – MULTIPLE ESTABLISHMENT INFORMATION

when an enterprise has more than one establishment con- ducting business in PA or employing PA residents, section 17, Parts 1 through 4 must be completed. Photocopy this section as necessary.

PART 1 - ESTABLISHMENT INFORMATION

1.Establishment Name: enter the name by which this establishment is known to the public; for example, the name on the front of the store.

2.Date of First Operations: enter the first date this estab- lishment conducted any activity in PA or employed PA res- idents. This includes start-up operations prior to opening for business.

3.Telephone Number: enter the telephone number for this establishment.

4.StreetAddress: enter the physical location of this establish- ment. A post office box is not acceptable.

5.PA School District: enter the school district where this establishment is located. if not a PA school district enter “n/A”.

6.PA Municipality: enter the municipality (borough, city, town or township) where this establishment is located. The municipality may be different from the city/town used for postal delivery. if not a PA municipality, enter “n/A”.

PART 2 - ESTABLISHMENT BUSINESS ACTIVITY INFORMATION

Refer to the instructions for establishment business Activity information (section 7).

PART 3 - ESTABLISHMENT SALES INFORMATION

Refer to the instructions for establishment sales information (section 8).

PART 4A & B - ESTABLISHMENT EMPLOYMENT INFORMATION

Refer to the instructions for establishment employment informa- tion (section 9).

SECTION 6A – ADDITIONAL OWNERS, PARTNERS, SHAREHOLDERS,

OFFICERS, AND RESPONSIBLE PARTY INFORMATION

Refer to the instructions for owners, Partners, shareholders, offi- cers, and Responsible Party information (section 6).

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

Complete Part 1 to apply for a PA sales and use Tax license or a Public Transportation Assistance Tax license that will autho- rize the enterprise to do any of the functions listed below. Appli- cations for a wholesale Certificate will only authorize the enterprise to do the function listed in bullet four:

•Collect state and local Sales Tax on taxable sales made within PA. local sales and use Tax is collected in those counties where required by statute.

•Remit state and local Use Tax incurred on property or ser- vices used within Pennsylvania where no sales Tax has been paid to a vendor.

•Collect taxes and fees on leases of motor vehicles, sales of new tires, and rentals of motor vehicles.

•Purchase tangible personal property and/or services for resale in the normal course of business sales tax-free.

24

PART 2 - TRANSIENT VENDOR CERTIFICATE

Complete Parts 1 and 2 to apply for a Transient vendor Certifi- cate. The certificate will authorize the enterprise to collect and remit sales Tax on taxable sales made within PA.

only enterprises whose business structure is a sole proprietor- ship or a partnership may apply for a transient vendor certificate.

A Transient Vendor Certificate is needed if the enterprise:

•Does not have a permanent sales & use Tax license.

•brings into PA, by automobile, truck or other means of trans- portation, or purchases in PA, tangible personal property that is subject to sales Tax, or comes into PA to perform services that are subject to PA sales Tax.

•offers or intends to offer tangible personal property for retail sale in PA.

•Does not maintain an established office, distribution house, sales house, warehouse, service enterprise or residence where business is conducted in PA.

The term “transient vendor” does not include an enterprise that does one of the following:

•Delivers tangible personal property solicited or placed by mail or telephone order.

•makes handcrafted items for sale at special events (e.g. fairs, carnivals, festivals, art and craft shows, and other cel- ebrations within Pennsylvania).

A Show is any event that involves the display or exhibition of any tangible personal property or services for sale. it may include, but is not limited to, a flea market, antique show, coin show, stamp show, comic book show, hobby show, automobile show, fair, or any similar show, if held regularly or temporarily where more than one vendor displays for sale or sells tangible personal property or services subject to sales Tax.

The Transient vendor Certificate is renewable on a yearly basis beginning february 1 of each year.

PART 3 - PROMOTER LICENSE

Complete Parts 1 and 3 to apply for a Promoter license. A Pro- moter is a person or enterprise who either directly or indirectly rents, leases, or otherwise operates or grants permission to any person to use space at a show for the display for sale or for the sale of tangible personal property or services subject to tax.

The Promoter‘s license is renewable on a yearly basis begin- ning february 1 of each year.

This application must be completed and returned to the Depart- ment of Revenue at least 30 days prior to the opening of the first show.

SECTION 19 – CIGARETTE DEALER‘S LICENSE

PART 1 - LICENSE TYPE

Complete section 19, Part 1 to apply for a Cigarette Dealer’s license. A separate license must be obtained for each location where retail sale of cigarettes, cigarette wholesale activity, or cig- arette tax stamping will occur.

A Cigarette Dealer’s license is not transferable.

if the enterprise is applying for a Cigarette vending machine license, form Rev-28, Cigarette vending machine location list- ing must be attached to the registration form. Provide the name of the establishment, street address, city, and county where each machine is located.

note: The Department of Revenue will allow the purchase of extra vending machine decals for machines to be placed at new loca- tions (up to 10 percent or 10 extra decals, whichever is greater) without submitting actual locations. within 30 days, licensees must advise the Department of the date an additional vending machine decal is affixed and the location of the machine.

All Cigarette Dealer’s licenses expire on the last day of february and are renewable on a yearly basis. license fees are not prorated.

PART 2 - CIGARETTE WHOLESALER

Complete Parts 1 and 2 to apply for a Cigarette wholesaler license.

All applicants for a Cigarette wholesaler or Cigarette stamping Agent license will be subject to a criminal background investiga- tion prior to the issuance of a license. This investigation will be completed within 60 days of receipt of the completed application.

PART 3 - CIGARETTE STAMPING AGENT

Complete Parts 1, 2, and 3 to apply for a Cigarette stamping Agent license.

SECTION 20 – SMALL GAMES OF CHANCE

LICENSE/CERTIFICATE

Complete Parts 1, 2, and 3 to apply for a Distributor license.

Complete Parts 1 and 3 to apply for a manufacturer Registra- tion Certificate.

Questions may be directed to (717) 787-8275.

PART 1 - DISTRIBUTOR AND/OR MANUFACTURER

The following items must be enclosed with the registration form.

•Corporations must submit a copy of the Certificate of incorporation, Articles of incorporation, Certificate of Authority (non-PA corporations), by-laws or Constitution. if doing business using a fictitious name, submit a copy of the fictitious name registration.

•The logo(s) used by the manufacturer.

•The fee for the Distributor license or the manufacturer Registration Certificate as listed on the registration form.

•A $22 nonrefundable background investigation fee for each owner, partner, officer, director, and shareholder controlling 10 percent or more of outstanding stock.

•Distributors and/or manufacturers must identify an agent and a physical location within Pennsylvania as a designee for purposes of service of process.

A Distributor license expires on April 30 and is renewable on a yearly basis.

Amanufacturer Registration Certificate expires on march 31 and is renewable on a yearly basis.

PART 2 - DISTRIBUTOR

Complete this section to apply for a Distributor license only.

PART 3 - SMALL GAMES OF CHANCE CERTIFICATION

Certification must be signed and notarized by all small games of Chance applicants.

SECTION 21 – MOTOR CARRIER REGISTRATION &

DECAL/MOTOR FUELS LICENSE & PERMIT

All enterprises applying for a motor Carrier Road Tax (mCRT)/ international fuel Tax Agreement (ifTA) Decal must complete Part 1.

25

The applicant’s authorized signature in section 4 of the form indicates applicant agrees to comply with the reporting, pay- ment, record keeping, and license display requirements as specified in mCRT and/or the ifTA.

PART 1 - VEHICLE OPERATIONS

A qualified motor vehicle is a motor vehicle used, designed, or maintained for the transportation of persons or property which has: (a) two axles and a gross or registered gross weight greater than 26,000 pounds, (b) three axles or more regardless of weight, or (c) a combination weight greater than 26,000 pounds.

MOTOR CARRIER ROAD TAX

Common Carrier:Any motor carrier which holds itself out to the general public to engage in the transportation by motor vehicle of passengers or property for compensation.

Contract Carrier: Any motor carrier transporting persons or property for compensation or hire under contract to a particular person, firm, or corporation.

For Hire Carrier: An enterprise providing transportation of pas- sengers or property by motor vehicle using the public utility com- mission rights of another carrier.

Private Carrier: A person, firm, or corporation which utilizes its own trucks to transport its own freight.

Truck: every motor vehicle designed, used, or maintained pri- marily for the transportation of property.

Truck Tractor: A motor vehicle designed and used primarily for drawing other vehicles but so constructed as to carry a load other than a part of the weight of the vehicle and load so drawn.

Combination: A power unit used in combination with trailers and semi-trailers.

Exemptions Include: vehicles operated by the u.s. govern- ment, the Commonwealth of PA and its political subdivisions, other states publicly-owned vehicles, volunteer fire, rescue and ambulance associations, farm vehicles, implements of hus- bandry, tow truck (not roll-backs), special mobile equipment, unladen vehicles being operated with a repair facility certificate from a PA repair facility, carriers who obtain permission from the PA state Police for emergency repair, and carriers operating on dealer or similar tags and operating vehicle incidental to their sale, demonstration, or repossession.

IFTADecals: Request ifTADecals for PA-qualified vehicles that travel in and outside of PA. An ifTA license must be carried in each vehicle and the vehicle must display decals on both sides of the cab.

Carriers purchasing ifTA credentials must file Quarterly ifTA fuel Tax reports.

Non-IFTADecals: for PA-qualified vehicles that travel exclusive- ly in PA, request non-ifTA Decals. Carriers from non-ifTA states operating qualified motor vehicles exclusively in PA must likewise display non-ifTA Decals. A Road Tax Cab Card must be carried in each vehicle and the vehicle must display decals on both sides of the cab. As of January 1, 2001, the only u.s. and Canadian jurisdictions not participating in ifTA are: Alaska, hawaii, District of Columbia, northwest Territories, and the yukon Territory.

Carriers purchasing non-ifTA credentials must maintain opera- tional records; however, quarterly motor Carrier Road Tax reports are not required.

if a carrier is based in a non-ifTA jurisdiction and intends to oper- ate qualified motor vehicles based in that state and travel in PA, complete this application to order non-ifTA Decals.

ALL DECALS ARE VALID FOR ONE CALENDAR YEAR.

make checks or money orders payable to the PA Department of Revenue. Allow two or three weeks for delivery of the decals. Do not send cash. if an ifTA decal is purchased, quarterly tax reports will be required.

for ifTA, decal, and tax information, contact the PA Department of Revenue, bureau of motor fuel Taxes at (1-800) 482-ifTA (4382) or (717) 787-5355, TT# 1-800-447-3020 (service for Customers with special hearing and/or speaking needs only).

PART 2 - FUELS

before the issuance of a liquid fuels and fuel Tax Permit, an on-site inspection contact will be made by the PA Department of Revenue, enforcement Division.

Asurety bond is required for liquid fuels and fuel Tax. The enter- prise will be contacted by the PADepartment of Revenue, bureau of motor fuel Taxes, enforcement Division, regarding the surety bond requirements.

SECTION 22 – SALES TAX EXEMPT STATUS FOR CHARITABLE

AND RELIGIOUS ORGANIZATIONS

Charitable, religious, non-profit educational institutions, and volunteer fire companies may be eligible for sales Tax exempt status.

Act 55 of 1997, known as the institutions of Purely Public Char- ity Act, changes the procedure and filing requirements for orga- nizations seeking to qualify or renew sales and use Tax exemption status.

To apply, a separate application (Rev-72) must be completed. see section 22, page 17 for more details. in addition to complet- ing the Rev-72, the following documents are required and must be attached to the application:

•A copy of the Articles of incorporation, by-laws, Consti- tution, or other governing legal document specifically including:

* Aims and purpose of the institution;

*A dissolution statement that expressly prohibits the use of any surplus funds for private inurement to any person in the event of a sale or dissolution of the institution.

•The most current financial statement (new organizations may substitute a proposed budget) including:

* All income and expenses listed by source and category:

*A list of the beneficiaries (individual, general public, other organizations, etc.) of the institution’s activities and how those beneficiaries are selected; and

*A list of sales activities (gift shop, bookstore, social club, etc.) used to raise funds. The institution must apply for a sales Tax license if engaging in sales activities.

•if the institution has tax exempt status with the internal Revenue service, a copy of the approval letter must be submitted.

•if the institution has voluntary agreements with political subdivisions, enclose copy of same.

•if the institution files form 990, provide a copy of the most recently completed form.

CONTACT US

DEPARTMENT OF REVENUE

 

 

 

LABOR & INDUSTRY

 

General Information

1-888-PATAXES

 

Unemployment Compensation (UC)

 

 

(728-2937)

 

 

UC Employer Help Line

717-787-7679

 

 

 

 

Taxpayer Service & Information Center

 

or Toll Free Help Line

1-866-403-6163

 

 

 

 

717-787-1064

 

 

Workers’ Compensation (WC)

717-783-5421

Online Customer Service

 

 

 

WC Employer Help Line

717-772-3702

 

 

 

or Toll Free Help Line

1-800-482-2383

www.revenue.pa.gov

 

 

 

 

 

 

 

 

 

 

 

 

E-mail:

 

 

 

 

 

UC-news@state.pa.us

 

PROGRAM QUESTIONS

UC Benefit Charges

717-787-4677

WC Self-Insurance Division

717-783-4476

WC Compliance Section

717-787-3567

26

Forms and information for both Departments are available at: www.pa100.state.pa.us

To verify the location of an office, please call Monday through Friday 8:30AM to 5:00 PM (EST) at the number listed for that office.

REVENUE DISTRICT OFFICES

Allentown

Ste. 4

555 Union Blvd.

Allentown, PA 18109-3389

(610) 861-2000

Erie

448 W. 11th St. Erie, PA 16501-1501

(814) 871-4491

Greensburg

Second Fl.

15 W. Third St.

Greensburg, PA 15601-3003

(724) 832-5386

Harrisburg

Lobby - Strawberry Sq. Harrisburg, PA 17128-0101

(717) 783-1405

Norristown

Second Fl.

Stoney Creek Office Center

151 W. Marshall St.

Norristown, PA 19401-4739

(610) 270-1780

Philadelphia

Ste 204A

110 N. 8th St. Philadelphia, PA 19107

(215) 560-2056

Philadelphia

Acadamy Plaza Shopping Center

3240 Red Lion Rd.

Philadelphia, PA 19114

(215) 560-2056

Pittsburgh - Downtown

411 7th Ave. - Room 420 Pittsburgh, PA 15219-1905

(412) 565-7540

Pittsburgh - Greentree

11 Parkway Ctr Ste. 175

875 Greentree Rd.

Pittsburgh, PA 15220-3623

(412) 929-0614

Reading

Ste. 239

625 Cherry St.

Reading, PA 19602-1186

(610) 378-4401

Scranton

Rm. 207

Bank Towers

207 Wyoming Ave.

Scranton, PA 18503-1970

(570) 963-4585

Sunbury

535 Chestnut St. Sunbury, PA 17801-2834

(570) 988-5520

LABOR & INDUSTRY FIELD ACCOUNTING SERVICE OFFICES

LOCATIONS AND COUNTIES SERVED

Allentown

 

Erie

 

Norristown East/West

 

Washington

 

1 s. second st., ste. 400

lehigh

1309 french st.

Crawford

1885 new hope st.

montgomery

millcraft Center, ste. 120ul

washington

Allentown, PA 18102-4901

northampton

erie, PA 16501-1999

erie

norristown, PA 19401-3146

 

90 w. Chestnut st.

 

(610) 821-6559

 

(814) 871-4381

 

(610) 270-1316 - East

 

 

 

 

 

 

 

 

 

 

 

(610) 270-3450 - West

 

washington, PA 15301

 

Altoona

bedford

Greensburg

 

 

 

(724) 223-4530

 

3303 Pleasant valley blvd.

blair

157 n. Penn. Ave. ste 1

west-

Philadelphia

 

 

 

 

 

Altoona, PA 16602-4311

Centre

greensburg, PA 15601-4458

moreland

444 n. Third st., ste. 3b

Philadelphia

Wilkes-Barre Central

 

(814) 946-6991

huntingdon

(724) 858-3944

 

Philadelphia, PA 19123-4190

 

 

 

 

 

 

 

(215) 560-3136/1828

 

 

 

 

 

 

 

 

39 Public square, suite 101

Carbon

Bristol

 

Harrisburg

 

Pittsburgh

 

wilkes barre, PA 18701

luzerne

1250 new Rodgers Rd.

bucks

16th fl., 333 market st.

Dauphin

 

(570) 301-1527

sullivan

933 Penn Ave., 2nd fl.

Allegheny

bristol, PA 19007-2591

 

harrisburg, PA 17101

Juniata

 

Pittsburgh, PA 15222-3815

 

 

 

(215) 781-3217

 

(717) 214-2991

lebanon

 

 

 

 

(412) 565-2400

 

Wilkes-Barre Pocono

 

 

 

 

mifflin

 

 

 

 

 

 

 

 

 

Carlisle

 

 

 

Reading

 

39 Public square, suite 101

monroe

1 Alexandra Ct.

Cumberland

Johnstown

 

 

wilkes barre, PA 18701

Pike

 

625 Cherry st., Rm. 250

berks

Carlisle, PA 17015-7667

 

200 lincoln st.

Armstrong

 

 

 

(717) 249-8211

 

Johnstown, PA 15901-1592

Cambria

Reading, PA 19602-1184

 

(570) 301-1533

 

 

(610) 378-4395/4511

 

 

 

(717) 697-1203

 

(814) 533-2371

indiana

 

 

 

 

 

 

 

 

Chambersburg

 

 

somerset

Scranton

 

Williamsport

 

 

 

 

135 franklin Ave.

bradford

208 w. Third st., ste. 301

Clinton

600 norland Ave., ste. 7

franklin

Lancaster

 

 

scranton, PA 18503-1935

lackawanna

williamsport, PA 17701-6477

lycoming

Chambersburg, PA 17201

fulton

29 e. King st., ste. 401

lancaster

(570) 963-4686

susquehanna

(570) 327-3525

Potter

(717) 264-7192

 

lancaster, PA 17602

 

 

wayne

 

 

(717) 299-7606

 

 

 

 

 

 

 

 

wyoming

 

Tioga

Chester

 

 

 

 

 

 

 

 

 

 

 

 

2nd fl., ste. D

Delaware

Malvern

 

Shamokin

 

York

 

701 Crosby st.

 

Century Plz., 2nd fl.

Chester

 

 

 

2 e. Arch st.

Columbia

 

 

 

 

Chester, PA 19013-6089

 

72 lancaster Ave.

 

841 vogelsong Rd.

Adams

 

 

Po box 279

montour

(610) 447-3290

 

malvern, PA 19355-2160

 

 

 

 

 

shamokin, PA 17872-0279

north-

york, PA 17404-1397

york

 

 

(610) 647-3799

 

(570) 644-3415

umberland

(717) 767-7620

 

Clearfield

 

 

 

 

 

 

 

 

schuylkill

 

 

501 e market st., ste. 6

Cameron

Mercer

 

 

 

 

 

 

snyder

Out-of-State

 

Clearfield, PA 16830

Clearfield

bldg. 2, ste. 2A

beaver

 

union

 

 

 

 

(814) 765-0572

elk

8419 sharon-mercer Rd.

butler

 

 

l & i bldg., Rm. 703

Perry

 

forest

mercer, PA 16137-3139

Clarion

Uniontown

 

651 boas st.

 

 

Jefferson

(724) 662-4007

lawrence

140 n. beeson Ave., ste. 403

fayette

 

 

harrisburg, PA 17121-0001

 

 

mcKean

 

mercer

uniontown, PA 15401-2937

greene

 

 

 

 

 

 

warren

 

venango

(724) 439-7230

 

(717) 787-5939

 

 

 

 

 

 

 

 

 

27

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form pa 100 online onewRegisTRATion, oADDingTAxesseRviCes, oReACTivATingTAxesseRviCes, oADDingesTAblishmenTs, oinfoRmATionuPDATe, SECTIONENTERPRISEINFORMATION, esTAblishmenTs, and ACCOUNTNUMBER fields to fill out

Indicate the rights and responsibilities of the sides inside the box o, CigAReTTe, DeAleRs, liCense o, CoRPoRATion, TAxes o, emPloyeR, wiThholDing, TAx, misC o, fuels, TAx, PeRmiT o, liQuiD, fuels, TAx, PeRmiT o, moToR, CARRieRs, RoAD, TAxi, fT, A o, PRomoTeR, liCense o, sAles, TAx, exemPT, sTATus o, sAles, use, hoTel, oCCuPAnCy, TAx, liCense o, smAll, gAmes, of, ChAnCel, iCC, eRT o, TRAnsienT, venDoR, CeRTifiCATe o, unemPloymenT, ComPensATion ouse, TAx o, vehiCle, RenTAl, TAx and o, wholesAleR, CeRTifiCATe

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