REV-181 (CM) 02-21

Department Use Only

APPLICATION FOR TAX

Bureau of Compliance CLEARANCE CERTIFICATE Revenue id

PO BOX 280947
Harrisburg PA 17128-0947 NO FILING FEE Please Type or Print
Start
1 name of Business Federal ein
➜
2 Location of Business (Current Mailing Address)
P.O. Box, Street and number or R.d. number and Box number Telephone number
( )
City or Town County State ZiP Code

3 name, Address and Phone number of Attorney or Representative to whom Clearance Certificate should be sent (if different from #2)
name Telephone number
( )
P.O. Box, Street and number or R.d. number and Box number

City or Town County State ZiP Code

4 name ( s), Home Address(es) and Social Security number(s) of Sole Proprietor, General Partners, Business Trustee, President and Treasurer of
the Corporation or Chief executive Officer or Majority Owner of entity. (Attach listing if necessary.)
name Social Security number Telephone number
( )
P.O. Box, Street and number or R.d. number and Box number City State ZiP Code

name Social Security number Telephone number

( )
P.O. Box, Street and number or R.d. number and Box number City State ZiP Code

5 Type of Business
dOMeSTiC CORPORATiOn (incorporated in PA) FOReiGn CORPORATiOn (not incorporated in PA) nOnPROFiT CORPORATiOn
(Please submit copy of 501(c)
PARTneRSHiP PROPRieTORSHiP exemption letter)
ASSOCiATiOn BuSineSS TRuST LiquidATinG TRuST
LiMiTed LiABiLiTy PARTneRSHiP OTHeR (Specify) LiMiTed LiABiLiTy COMPAny
if domestic Corporation, give incorporation date. if Foreign Corporation, give state where incorporated and date of Certificate of Authority in PA.
MM/DD/YYYY MM/DD/YYYY
Registered Pennsylvania Address, P.O. Box, Street and number

City or Town County State ZiP Code

date business started in Pennsylvania date terminated

MM/DD/YYYY MM/DD/YYYY
6 describe the business activity in Pennsylvania, including services performed and rendered, and give principal commodity sold at wholesale or
retail. if sales or construction are involved, please explain. if manufacturer’s representatives or independent contractors perform activities,
render services or execute sales on behalf of the entity rather than entity’s employees, please specify what activities were performed, what
services were rendered and what type of sales were executed.

7 did the entity have employees for which PA personal income tax was required to be withheld from wages?

8 did taxpayer ever hold any of the following licenses, permits or accounts with the Commonwealth of PA? MM/DD/YYYY
(a) Corporation Tax yes no Period to Revenue id no.
(b) Malt Beverage or Liquor License yes no Period to License no.
(c) Liquid Fuels yes no Period to Permit no.
(d) Cigarette Tax yes no Period to License no.
(e) Sales, use and Hotel Occ. Tax yes no Period to License no.
(f) Motor Carrier yes no Period to License no.
(g) Fuel dealer-user yes no Period to License no.
(h) Lottery yes no Period to Agent no.
(i) Small Games of Chance Mfg. / distr. yes no Period to License no.
(j) Public Transportation Assistance yes no Period to License no.
(k) PA unemployment Compensation yes no Period to Account no.
(l) PA Oil Company Franchise Tax yes no Period to Account no.

Reset Entire Form NEXT PAGE PRINT FORM

 Page 2

9 Were the assets or activities of the business acquired in whole or in part from a prior business entity?
Yes No ( If “Yes”, give predecessor’s name, address and acquisition date. )
Name Acquisition Date
MM/DD/YYYY
P.O. Box, Street and Number

City or Town County State ZIP Code

10 Has the business held title to any real estate in the last five years from the date of this application? Yes No

l If “Yes”, complete Schedule A (last page).

l If you currently hold title to real estate in PA, complete Schedule B (last page).

11 Will the assets or activities of the business be transferred to another? If “Yes”, complete:
Name of New Owner
A. Corporation Yes No F. Other Yes No
B. Partnership Yes No Explain:
Street Address of New Owner
C. Proprietorship Yes No
D. Liquidating Trust Yes No
City State ZIP Code
E. Association Yes No
12 Purpose of Clearance Certificate (check appropriate block):

A. Dissolution of Corporation or Association through Department of State.

B. Dissolution of Corporation or Association through Court of Common Pleas. Date Court was petitioned and county:

(date) MM/DD/YYYY (county)

C. Withdrawal of Foreign Corporation through Department of State

D. Merger or consolidation of two or more Corporations or Associations where surviving Corporation or Association is not subject to the
jurisdiction of Pennsylvania. (See 15 Pa C.S. § 139.)
E. Bulk Sale Clearance Certificate under Section 1403 of the Fiscal Code. Sale date: MM/DD/YYYY
Copy of settlement statement:
Corporation Tax Purposes Employer Withholding Tax Purposes Sales, Use and Hotel Occupancy Tax Purposes

Unemployment Compensation Tax Purposes

STATEMENT OF AUTHORIZATION
I authorize the PA Department of Revenue to disclose, verbally or in written form, all tax filings, payments or delinquencies
requested by the buyer or his representatives for the bulk sale transfer provision. MM/DD/YYYY

Authorized by Title Date

F. Foreign Corporation Clearance Certificate under the provisions of the Act of 1947, P.L. 493, Contract Number and Political Subdivision:

13 Location of business records, available for audit of Pennsylvania operations.

P.O. Box, Street and Number City State ZIP Code

Telephone Number
14 List any matters pending with the PA Department of Revenue (e.g. petitions, appeals):

15 Did the business ever, within the Commonwealth of PA: MM/DD/YYYY

(a) Engage in the sale of soft drinks or soft drink syrup ........................................................ Yes No Period to
(b) Own or lease and operate diesel-powered motor vehicles on PA highways?.................... Yes No Period to
(c) Engage in the sale of diesel fuel to motor vehicles using PA highways? .......................... Yes No Period to
(d) Engage in the sale or lease of tangible personal property since Sept. 1, 1953? .............. Yes No Period to
(e) File PA Unemployment Compensation Reports?................................................................ Yes No Period to
If “Yes”, give Account Number (See question 8k.)

16 Have you terminated your business activities in Pennsylvania?

Yes No
l If “Yes”, give distribution of assets date: MM/DD/YYYY

l If “No”, explain:
l If a Foreign Corporation, have you terminated business in the state of your incorporation? Yes No

Reset Entire Form RETURN TO PAGE 1 NEXT PAGE PRINT FORM

 Page 3

17 number of employees and total gross payrolls during the last five operating years (as reported to the Social Security Administration):
yeAR TOTAL eMPLOyeeS PA TOTAL GROSS PA
eMPLOyeeS PAyROLL GROSS PAyROLL

18 Have the officers received any remuneration, in cash or other other form, for services performed in Pennsylvania during the current calendar
year or during any of the preceding four calendar years?
yes no
19 Were any remunerated services performed for the business in PA, which you believe did not constitute “employment” as defined
in the PA unemployment Compensation Law? yes no
if “yes”, explain:

20 A. Average number of stockholders during the last five years:

B. number of stockholders as of this report:

C. List names and home addresses of stock transfer agents who have handled the corporation’s stock:
name: Address:

d. Were all shares presented and property redeemed from any stock called for redemption or retired? yes no

21 The figures below must agree with the last corporate tax report filed with the PA department of Revenue.
date of Report: MM/DD/YYYY Total Liabilities:

Total Assets: Total equity (net worth):

22 A. List the amount of corporate bonds issued and still outstanding as of this report. Show each issue separately and include name and
address of any transfer or paying agents.
issue Agent number of Outstanding Bonds Amount

B. List names and addresses of transfer or paying agents not listed above who have handled corporate bond issues.
name: Address:

23 Have you consumed or used in Pennsylvania any tangible personal property or acquired such, after March 6, 1956, on which no PA sales or use
tax was paid? if “yes”, please explain:
yes no
24 do you have within your custody, possession or control any abandoned and unclaimed (escheatable) funds or assets such as dividends,
payroll, deposits, outstanding checks, stock certificates, unidentified deposits, accounts payable debit balances, gift certificates, outstanding
debentures or interest, royalties, mineral rights or funds due missing shareholders or other unclaimed amounts payable?
yes no
25 Has the business filed a PA Abandoned and unclaimed Property Report for the preceding year?
yes no
26 CeRTiFiCATiOn: i certify that the information provided (including Schedules, if applicable) on this application has been examined by me and
is, to the best of my knowledge, true and correct. (Certification must agree with individuals listed in question 4.)

Print name Original Signature Signature of Officer – Please sign after printing

Print name Original Signature Signature of Officer – Please sign after printing

This form will serve as an application for clearances from both the PA department of Revenue and PA department of Labor & industry.
nOTe: l Submit typed original to the PA department of Revenue (address on Page 1) and one copy to the PA dePARTMenT OF LABOR &
induSTRy, OFFiCe OF uneMPLOyMenT COMPenSATiOn TAX SeRviCeS, e-GOveRnMenT uniT, LABOR & induSTRy BuiLdinG, ROOM
916, 651 BOAS ST., HARRiSBuRG PA 17121. Retain a copy for taxpayer’s record.
l direct telephone inquiries to the PA department of Revenue at 717-783-6052 or at 717-346-2001. Services for taxpayer with special
hearing /speaking needs can be accessed at 1-800-447-3020. Call the PA department of Labor & industry at 866-403-6163, Option 2
or 717-783-3545 for services for the hearing impaired.

Reset Entire Form RETURN TO PAGE 1 NEXT PAGE PRINT FORM

SCHEDULE A - STATEMENT OF ACQUISITION AND/OR DISPOSITION OF PENNSYLVANIA REAL ESTATE WITHIN FIVE YEARS FROM THE DATE OF THIS APPLICATION
Name of Transferee (EE) Original Cost Actual Consider-
Property Location by Actual Monetary Worth Amount of PA Realty
or Transferor (OR). Date of Acquisition County ation including
Local Political Subdivision (Market Value) Stamps Affixed to
Indicate each by symbol Transfer Date Land Building Assessed Value Encumbrance Explanation
EE or OR.
MM/DD/YYYY
& County
MM/DD/YYYY
Assumed * *
at Time of Transfer Document **

Property Location by Original Cost Actual Consider- Actual Monetary Worth Amount of PA Realty
Acquisition County ation including
Local Political Subdivision (Market Value) Stamps Affixed to
Date Land Building Assessed Value Encumbrance Explanation
& County
MM/DD/YYYY Assumed * *
at Time of Transfer Document **

SCHEDULE B
STATEMENT
OF ALL
PENNSYLVANIA
REAL ESTATE
NOW OWNED

List all real estate now owned in PA that the business will dispose of prior to or at the time of the action for which a clearance is required.
If under agreement of disposition, attach copy of executed agreement for each property so affected.
* Complete if applicable. If transfer represents less than a full fee-simple interest in the property, explain on a separate sheet of paper.
** If no realty transfer tax was paid, explain on attached sheet or in “Explanation” column above.
If application is for a Bulk Sale Clearance Certificate, attach a list of PA properties that will be retained. For each property, provide the complete address,
including county, date of acquisition and nature of property (residential, industrial, acreage, commercial or farmland). If none, state none.

Reset Entire Form RETURN TO PAGE 1 PRINT FORM