PA Enterprise Registration Form and Instructions (PA-100)

PA-100 (8-01)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF BUSINESS TRUST FUND TAXES
DEPT. 280901
HARRISBURG, PA 17128-0901
Go Paperless . . .
REGISTER ON THE INTERNET
www.paopen4business.state.pa.us
P E N N S Y LVA N I A
ENTERPRISE
REGISTRATION
F O R M AN D I N STR U CTI O N S
DETACH AND MAIL COMPLETED REGISTRATION FORM TO:
COMMONWEALTH OF PA • DEPARTMENT OF REVENUE • BUREAU OF BUSINESS TRUST FUND TAXES • DEPT. 280901 • HARRISBURG, PA 17128-0901
P E N N S Y LVA N I A E N T E R P R I S E R E G I S T R AT I O N
The Pennsylvania Enterprise Registration Form (PA-100) must be completed by enterprises to register for certain taxes and services
administered by the PA Department of Revenue and the PA Department of Labor & Industry. The form is also designed to be used by previously registered enterprises to register for additional taxes and services, reactivate a tax or service, or notify both Departments that additional establishment locations have been added. The form is also used to request the Unemployment Compensation Experience Record and
Reserve Account Balance of a Predecessor.
For registration assistance, contact:
(717) 787-1064, Monday through Friday 8:00 AM to 4:30 PM (EST); Service for Customers with special hearing and/or speaking needs
(TT only) 1-800-447-3020.
What is an enterprise?
An enterprise is any individual or organization, sole-proprietorship,
partnership, corporation, government organization, business trust,
association, etc., which is subject to the laws of the Commonwealth of
Pennsylvania and performs at least one of the following:
Pays wages to employees
Offers products for sale to others
Offers services for sale to others
Collects donations
Collects taxes
Is allocated use of tax dollars
Has a name which is intended for use and, by that name, is to be
recognized as an organization engaged in economic activity.
How to complete the registration form:
New registrants must complete every item in Sections 1
through 10 and additional sections as indicated.
Registered enterprises must complete every item in Sections
1 through 4 and additional sections as indicated.
Section 5 has indicators to direct the registrant to additional
sections.
To determine the registration requirements for a specific tax service and/or license, see pages 2 and 3.
Type or print legibly using black ink.
Enter all dates in MM/DD/YYYY format (E.G. 10/22/2001).
Retain a copy of the completed registration form for your records.
What is an establishment?
An establishment is an economic unit, generally at a single physical
location where:
Business is conducted inside PA
Business is conducted outside PA with reporting
requirements to PA
PA residents are employed, inside or outside of PA.
The enterprise and the establishment may have the same physical
location.
Multiple establishments exist if the following apply:
Business is conducted at multiple locations.
Distinct and separate economic activities involving separate
employees are performed at a single location. Each activity may
be treated as a separate establishment as long as separate
reports can be prepared for the number of employees, wages
and salaries, or sales and receipts.
How to avoid delays in processing:
Review the registration form and accompanying sections to be
sure that every item is complete. The preparer will be contacted
to supply information if required sections are not completed.
Enclose payment for license or registration fees, payable to
PA Department of Revenue.
If a quarterly UC Report/payment is submitted, attach a separate
check payable to PA Unemployment Compensation Fund.
Sign the registration form.
Remove completed pages from the booklet, arrange in sequential order, and mail to the PA Department of Revenue.
It is your responsibility to notify the Bureau of Business Trust Fund Taxes in writing within 30 days of any change to the information provided on the registration form.
Completing this form will NOT fulfill the requirement to register for corporate taxes. Registering corporations must also contact the PA Department of State
to secure corporate name clearance and register for corporation tax purposes. Contact the PA Department of State at (717) 787-1057, or visit
www.paopen4business.state.pa.us.
TA B L E O F C O N T E N T S
Form
Page
Sec.
Inst.
Page
Form
Page
Sec.
Inst.
Page
Mailing Address . . . . . . . . . . . . . . . . . . . . . . . . . .Front Cover
13
Government Structure . . . . . . . . . . . . . . . . . . . .7 . . . .22-23
Taxes and Services (definitions & requirements) . . . . . . . .2-3
14
Predecessor/Successor Information . . . . . . . . . .8 . . . . . . .23
1
Reason for this Registration . . . . . . . . . . . . . . . .4 . . . . . . .18
15
2
Enterprise Information . . . . . . . . . . . . . . . . . . . .4 . . . . . . .18
Application for PA UC Experience Record & . . . .9 . . . . . . .23
Reserve Account Balance of Predecessor
3
Taxes & Services . . . . . . . . . . . . . . . . . . . . . . . .4 . . . . . . .19
16
4
Authorized Signature . . . . . . . . . . . . . . . . . . . . .4 . . . . . . .19
Unemployment Compensation Partial . . . . . . . . .9 . . . .23-24
Transfer Information
5
Business Structure . . . . . . . . . . . . . . . . . . . . . .5 . . . . . . .19
17
Multiple Establishment Information . . . . . . . . . . .10-11 . . .24
6
Owners, Partners, Shareholders, Officers, . . . . .5 . . . . . . .19
Responsible Party Information
18
6a
Additional Owners, Partners, Shareholders,
Officers, Responsible Party Information
Sales Use and Hotel Occupancy Tax License, . .12 . . .24-25
Public Transportation Assistance Tax License,
Vehicle Rental Tax, Transient Vendor
Certificate, Promoter License, or Wholesaler Certificate
19
Cigarette Dealer’s License . . . . . . . . . . . . . . . . .13 . . . . . .25
7
Establishment Business Activity Information . . . .5 . . . .20-21
20
Small Games of Chance License/Certificate . . . .14-15 . . .25
8
Establishment Sales Information . . . . . . . . . . . .6 . . . . . . .22
9
Establishment Employment Information . . . . . . .6 . . . . . . .22
21
Motor Carrier Registration & Decal/Motor
Fuels License & Permit
10
Bulk Sale/Transfer Information . . . . . . . . . . . . . .6 . . . . . . .22
22
11
Corporation Information . . . . . . . . . . . . . . . . . . .7 . . . . . . .22
Sales Tax Exempt Status for Charitable and . . . .17 . . . . . .26
Religious Organizations
12
Reporting & Payment Methods . . . . . . . . . . . . . .7 . . . . . . .22
Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . .26-27
1
. . .11 . . . . . .19
. . . . .16 . . .25-26
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 4 plus the additional sections indicated.
TAXES AND SERVICES
CIGARETTE TAX IS AN EXCISE TAX IMPOSED ON THE SALE OR POSSESSION OF
CIGARETTES. A DEALER IS ANY CIGARETTE STAMPING AGENT, WHOLESALER,
OR RETAILER.
CORPORATION TAXES ARE IMPOSED ON DOMESTIC AND FOREIGN CORPORATIONS, CERTAIN BUSINESS TRUSTS, AND LIMITED LIABILITY COMPANIES WHICH
ARE REGISTERED AND/OR TRANSACTING BUSINESS WITHIN THE COMMONWEALTH OF PENNSYLVANIA. SUBJECTIVITY TO SPECIFIC CORPORATION TAXES IS
DETERMINED BY THE TYPE OF CORPORATE ORGANIZATION AND THE ACTIVITY
CONDUCTED.
FINANCIAL INSTITUTIONS TAXES: THE BANK AND TRUST COMPANY SHARES
TAX IS IMPOSED ON EVERY BANK AND TRUST COMPANY HAVING CAPITAL
STOCK AND CONDUCTING BUSINESS IN PENNSYLVANIA. DOMESTIC TITLE
INSURANCE COMPANIES ARE SUBJECT TO THE TITLE INSURANCE COMPANY
SHARES TAX. THE MUTUAL THRIFT INSTITUTIONS TAX IS IMPOSED ON SAVINGS INSTITUTIONS, SAVINGS BANKS, SAVINGS AND LOAN ASSOCIATIONS,
AND BUILDING AND LOAN ASSOCIATIONS CONDUCTING BUSINESS IN PENNSYLVANIA. CREDIT UNIONS ARE NOT SUBJECT TO TAX.
GROSS PREMIUMS TAX IS LEVIED ON DOMESTIC AND FOREIGN INSURANCE
COMPANIES. THE YEARLY GROSS PREMIUMS RECEIVED FORM THE TAX
BASE. GROSS PREMIUMS ARE PREMIUMS, PREMIUM DEPOSITS, OR
ASSESSMENTS, FOR BUSINESS TRANSACTED IN PENNSYLVANIA.
GROSS RECEIPTS TAX IS LEVIED ON PIPELINE, CONDUIT, WATER NAVIGATION AND TRANSPORTATION COMPANIES; TELEPHONE AND TELEGRAPH
COMPANIES; ELECTRIC LIGHT, WATER POWER AND HYDROELECTRIC COMPANIES; AND FREIGHT AND OIL TRANSPORTATION COMPANIES.
SECTIONS TO
COMPLETE
REQUIREMENTS
CIGARETTE DEALER’S
LICENSE
SECTION 19
SALES TAX LICENSE
(RETAILER)
SECTION 18
REGISTRATION WITH
PA DEPARTMENT OF STATE
FORMS MUST BE OBTAINED
FROM PA DEPARTMENT OF
STATE
SECTION 11
REGISTRATION WITH FEDERAL OR STATE AUTHORITY
THAT GRANTED CHARTER
REGISTRATION WITH
PA DEPARTMENT OF
INSURANCE
REGISTRATION WITH PA
PUBLIC UTILITY
COMMISSION
REGISTRATION WITH PA
PUBLIC UTILITY COMMISSION
REGISTRATION WITH PA
DEPARTMENT OF STATE
SECTION 9
SECTION 21
SECTION 21
THE TAX IS BASED ON GROSS RECEIPTS FROM PASSENGERS, BAGGAGE
AND FREIGHT TRANSPORTED WITHIN PENNSYLVANIA; TELEGRAPH AND
TELEPHONE MESSAGES TRANSMITTED WITHIN PENNSYLVANIA; AND SALES
OF ELECTRICITY IN PENNSYLVANIA.
PUBLIC UTILITY REALTY TAX IS LEVIED AGAINST CERTAIN ENTITIES FURNISHING UTILITY SERVICES. PENNSYLVANIA IMPOSES THIS TAX ON PUBLIC
UTILITY REALTY IN LIEU OF LOCAL REAL ESTATE TAXES AND DISTRIBUTES
THE LOCAL REALTY TAX EQUIVALENT TO LOCAL TAXING AUTHORITIES.
OTHER CORPORATION TAXES: THIS GROUP IS COMPOSED PRIMARILY OF
THE CORPORATE LOANS TAX, THE COOPERATIVE AGRICULTURAL ASSOCIATION AND ELECTRIC COOPERATIVE CORPORATION TAXES.
EMPLOYER WITHHOLDING IS THE WITHHOLDING OF PENNSYLVANIA PERSONAL
INCOME TAX BY EMPLOYERS FROM COMPENSATION PAID TO PENNSYLVANIA
RESIDENT EMPLOYEES FOR WORK PERFORMED INSIDE OR OUTSIDE OF PENNSYLVANIA AND NONRESIDENT EMPLOYEES FOR WORK PERFORMED INSIDE
PENNSYLVANIA. (SEE UNEMPLOYMENT COMPENSATION DEFINITION)
LIQUID FUELS AND FUELS TAX IS AN EXCISE TAX IMPOSED ON ALL LIQUID FUELS
AND FUELS USED OR SOLD AND DELIVERED BY DISTRIBUTORS WITHIN PENNSYLVANIA, EXCEPT THOSE DELIVERED TO EXEMPT PURCHASERS. LIQUID FUELS
INCLUDE GASOLINE, GASOHOL, JET FUEL, AND AVIATION GASOLINE. FUELS
INCLUDE CLEAR DIESEL FUEL AND KEROSENE. ADDITIONALLY, THE LIQUID
FUELS AND FUELS TAX ACT TAXES ALTERNATIVE FUELS (i.e. HIGHWAY FUELS
OTHER THAN LIQUID FUELS OR FUELS) AT A RETAIL/USE TAX LEVEL.
MOTOR CARRIERS ROAD TAX IS IMPOSED ON MOTOR CARRIERS ENGAGED IN
OPERATIONS ON PENNSYLVANIA HIGHWAYS. A MOTOR CARRIER IS ANY PERSON
OR ENTERPRISE OPERATING A QUALIFIED MOTOR VEHICLE USED, DESIGNED,
OR MAINTAINED FOR THE TRANSPORTATION OF PERSONS OR PROPERTY
WHERE (A) THE POWER UNIT HAS TWO AXLES AND A GROSS OR REGISTERED
GROSS WEIGHT GREATER THAN 26,000 POUNDS, (B) THE POWER UNIT HAS
THREE AXLES OR MORE REGARDLESS OF WEIGHT, OR (C) VEHICLES ARE USED
IN COMBINATION AND THE DECLARED COMBINATION WEIGHT EXCEEDS 26,000
POUNDS OR THE GROSS WEIGHT OF THE VEHICLES EXCEEDS 26,000 POUNDS.
LIQUID FUELS AND FUELS
TAX PERMIT
IFTA LICENSE AND
IFTA DECALS
PA NON-IFTA VEHICLE
REGISTRATION AND PA NONIFTA DECALS
2
PROMOTER IS ANY ENTERPRISE ENGAGED IN RENTING, LEASING, OR GRANTING
PERMISSION TO ANY PERSON TO USE SPACE AT A SHOW FOR THE DISPLAY OR
FOR THE SALE OF TANGIBLE PERSONAL PROPERTY OR SERVICES.
PUBLIC TRANSPORTATION ASSISTANCE TAX IS A TAX OR FEE IMPOSED ON EACH
SALE IN PENNSYLVANIA OF NEW TIRES FOR HIGHWAY USE, ON THE LEASE OF
MOTOR VEHICLES, AND ON THE RENTAL OF MOTOR VEHICLES. THE TAX IS ALSO
LEVIED ON THE STATE TAXABLE VALUE OF UTILITY REALTY OF ENTERPRISES
SUBJECT TO THE PUBLIC UTILITY REALTY TAX AND ON PETROLEUM REVENUE OF
OIL COMPANIES.
REPORTING AND PAYMENT METHODS OFFER THE TAXPAYER THE ABILITY TO FILE
CERTAIN TAXES THROUGH ELECTRONIC DATA INTERCHANGE (EDI) AND TO MAKE
PAYMENT THROUGH ELECTRONIC FUNDS TRANSFER (EFT). UNEMPLOYMENT
COMPENSATION (UC) WAGES MAY BE REPORTED VIA A MAGNETIC MEDIUM. IN
CERTAIN INSTANCES, AN ENTERPRISE MAY ELECT TO FINANCE UC COSTS UNDER
A REIMBURSEMENT METHOD RATHER THAN THE CONTRIBUTORY METHOD.
SALES TAX IS AN EXCISE TAX IMPOSED ON THE RETAIL SALE OR LEASE OF TAXABLE, TANGIBLE PERSONAL PROPERTY, AND ON SPECIFIED SERVICES.
HOTEL OCCUPANCY TAX IS AN EXCISE TAX IMPOSED ON EVERY HOTEL OR
MOTEL ROOM OCCUPANCY LESS THAN THIRTY (30) CONSECUTIVE DAYS.
LOCAL SALES TAX MAY BE IMPOSED, IN ADDITION TO THE STATE SALES AND
USE TAX, ON THE RETAIL SALE OR USE OF TANGIBLE PERSONAL PROPERTY
AND SERVICES AND ON HOTEL/MOTEL OCCUPANCIES IN COUNTIES THAT
HAVE ENACTED SUCH ORDINANCES.
SALES TAX EXEMPT STATUS FOR CHARITABLE AND RELIGIOUS ORGANIZATIONS
IS THE QUALIFICATION OF AN INSTITUTION OF PURELY PUBLIC CHARITY TO BE
EXEMPT FROM SALES AND USE TAX ON THE PURCHASE OF TANGIBLE PERSONAL
PROPERTY OR SERVICES FOR USE IN CHARITABLE ACTIVITY.
SMALL GAMES OF CHANCE IS THE REGULATION OF LIMITED GAMES OF CHANCE
THAT QUALIFIED CHARITABLE AND NON-PROFIT ORGANIZATIONS CAN OPERATE
IN PENNSYLVANIA.
PROMOTER LICENSE
SECTION 18
SALES USE AND HOTEL
OCCUPANCY TAX LICENSE
PUBLIC TRANSPORTATION
ASSISTANCE TAX LICENSE
SECTION 18
AUTHORIZATION
AGREEMENT
SECTION 12
SALES USE AND HOTEL
OCCUPANCY TAX LICENSE
SECTION 18
SALES USE AND HOTEL
OCCUPANCY TAX LICENSE
SECTION 18
SALES USE AND HOTEL
OCCUPANCY TAX LICENSE
SECTION 18
CERTIFICATE OF EXEMPT
SALES TAX STATUS
SECTION 22
SMALL GAMES OF CHANCE
DISTRIBUTOR LICENSE
AND/OR
MANUFACTURER
REGISTRATION CERTIFICATE
SECTION 20
TRANSIENT VENDOR
CERTIFICATE
SECTION 18
SECTIONS 7, 9,
IF APPLICABLE 10
AND 14
SECTIONS 14, 15
IF APPLICABLE, 16
SECTION 18
SECTION 18
TRANSIENT VENDOR IS ANY ENTERPRISE WHOSE BUSINESS STRUCTURE IS SOLE
PROPRIETOR OR PARTNERSHIP, NOT HAVING A PERMANENT PHYSICAL BUSINESS
LOCATION IN PENNSYLVANIA, WHICH SELLS TAXABLE, TANGIBLE PERSONAL
PROPERTY OR PERFORMS TAXABLE SERVICES IN PENNSYLVANIA.
UNEMPLOYMENT COMPENSATION (UC) PROVIDES A FUND FROM WHICH COMPENSATION IS PAID TO WORKERS WHO HAVE BECOME UNEMPLOYED THROUGH
NO FAULT OF THEIR OWN. CONTRIBUTIONS ARE REQUIRED TO BE MADE BY ALL
EMPLOYERS WHO PAY WAGES TO INDIVIDUALS WORKING IN PA AND WHOSE SERVICES ARE COVERED UNDER THE UC LAW. THIS TAX MAY INCLUDE EMPLOYEE
CONTRIBUTIONS WITHHELD BY EMPLOYERS FROM EACH EMPLOYEE’S GROSS
WAGES. (SEE EMPLOYER WITHHOLDING DEFINITION)
APPLICATION FOR PA UC EXPERIENCE RECORD AND RESERVE ACCOUNT
BALANCE ENABLES THE REGISTERING ENTERPRISE TO BENEFIT FROM A
PREDECESSOR’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 SALES TAX HAS NOT BEEN PAID.
USE TAX ACCOUNT
VEHICLE RENTAL TAX IS IMPOSED ON RENTAL CONTRACTS BY ENTERPRISES
HAVING AVAILABLE FOR RENTAL: (1) 5 OR MORE MOTOR VEHICLES DESIGNED TO
CARRY 15 OR LESS PASSENGERS, OR (2) TRUCKS, TRAILERS, OR SEMI-TRAILERS
USED IN THE TRANSPORTATION OF PROPERTY. A RENTAL CONTRACT IS FOR A
PERIOD OF 29 DAYS OR LESS.
SALES USE AND HOTEL
OCCUPANCY TAX LICENSE
WHOLESALER CERTIFICATE PERMITS AN ENTERPRISE SOLELY ENGAGED IN
SELLING TANGIBLE PERSONAL PROPERTY AND/OR SERVICES FOR RESALE OR
RENTAL. TO PURCHASE TANGIBLE PERSONAL PROPERTY OR SERVICES FOR
RESALE OR RENTAL SALES TAX-FREE WHEN USED IN THE NORMAL COURSE OF
THE ENTERPRISE’S BUSINESS.
APPLICATION FOR
EXPERIENCE RECORD AND
RESERVE ACCOUNT
BALANCE OF PREDECESSOR
PTA LICENSE
WHOLESALER CERTIFICATE
SECTION 18
WORKERS’ COMPENSATION
COVERAGE
SECTION 9
WORKERS’ COMPENSATION COVERAGE IS MANDATORY AND PROTECTS EMPLOYERS FROM LIABILITY FOR WAGE LOSS AND MEDICAL BENEFITS INCURRED AS A
RESULT OF EMPLOYEES’ JOB RELATED INJURIES OR DISEASES.
ENTERPRISES WHO EMPLOY AT LEAST ONE EMPLOYEE WHO COULD BE INJURED
OR DEVELOP A WORK RELATED DISEASE IN PA OR OUTSIDE OF PA WHILE UNDER A
CONTRACT OF HIRE MADE IN PA, IF THE EMPLOYMENT IS PRINCIPALLY LOCALIZED
IN PA, NOT PRINCIPALLY LOCALIZED IN ANY STATE, OR PRINCIPALLY LOCALIZED IN
ANY STATE WHOSE WORKERS’ COMPENSATION LAWS DO NOT APPLY, MUST INSURE
THEIR WORKERS’ COMPENSATION LIABILITY BY PURCHASING A WORKERS’ COMPENSATION POLICY THROUGH AN INSURANCE COMPANY OR BY SECURING THE
AUTHORITY TO SELF-INSURE. ENTERPRISES ARE EXCLUDED FROM THE REQUIREMENT TO INSURE THEIR WORKERS’ COMPENSATION LIABILITY IF ALL WORKERS
EMPLOYED BY IT FALL INTO ONE OR MORE OF THE EXEMPT CATEGORIES.
3
PA-100 (1) 8-01
RECEIVED DATE
COMMONWEALTH OF PENNSYLVANIA
MAIL COMPLETED APPLICATION TO:
DEPARTMENT OF REVENUE
BUREAU OF BUSINESS TRUST FUND TAXES
DEPT. 280901
HARRISBURG, PA 17128-0901
TELEPHONE (717) 772-2340
PA ENTERPRISE
REGISTRATION FORM
DEPARTMENT USE ONLY
DEPARTMENT OF REVENUE &
DEPARTMENT OF LABOR AND INDUSTRY
TYPE OR PRINT LEGIBLY, USE BLACK INK
SECTION 1 – REASON FOR THIS REGISTRATION
REFER TO THE INSTRUCTIONS (PAGE 18) AND CHECK THE APPLICABLE BOX(ES) TO INDICATE THE REASON(S) FOR THIS REGISTRATION.
1.
2.
3.
4.
5.
6. DID THIS ENTERPRISE:
NEW REGISTRATION
ADDING TAX(ES) & SERVICE(S)
REACTIVATING TAX(ES) & SERVICE(S)
YES
NO ACQUIRE ALL OR PART OF ANOTHER BUSINESS?
YES
YES
NO UNDERGO A MERGER, CONSOLIDATION, DISSOLUTION, OR OTHER RESTRUCTURING?
ADDING ESTABLISHMENT(S)
INFORMATION UPDATE
NO RESULT FROM A CHANGE IN LEGAL STRUCTURE (FOR EXAMPLE, FROM INDIVIDUAL
PROPRIETOR TO CORPORATION, PARTNERSHIP TO CORPORATION, CORPORATION
TO LIMITED LIABILITY COMPANY, ETC)?
SECTION 2 – ENTERPRISE INFORMATION
1. DATE OF FIRST OPERATIONS
2. DATE OF FIRST OPERATIONS IN PA
3. ENTERPRISE FISCAL YEAR END
4. ENTERPRISE LEGAL NAME
5. FEDERAL EMPLOYER IDENTIFICATION NUMBER (EIN)
6. ENTERPRISE TRADE NAME (if different than legal name)
7. ENTERPRISE TELEPHONE NUMBER
(
8. ENTERPRISE STREET ADDRESS (do not use PO Box)
CITY/TOWN
)
COUNTY
STATE
ZIP CODE + 4
9. ENTERPRISE MAILING ADDRESS (if different than street address)
CITY/TOWN
STATE
ZIP CODE + 4
10. LOCATION OF ENTERPRISE RECORDS (street address)
CITY/TOWN
STATE
ZIP CODE + 4
11. ESTABLISHMENT NAME (doing business as)
12. NUMBER OF
ESTABLISHMENTS *
13. SCHOOL DISTRICT
14. MUNICIPALITY
* Enterprises with more than one establishment as defined in the general instructions must complete Section 17.
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 NBR.
PREVIOUS
ACCOUNT NBR.
CIGARETTE DEALER’S LICENSE
CORPORATION TAXES
EMPLOYER WITHHOLDING TAX
FUELS TAX PERMIT
LIQUID FUELS TAX PERMIT
LOCAL SALES, USE, HOTEL OCCUPANCY TAX
MOTOR CARRIERS ROAD TAX/IFTA
PROMOTER LICENSE
PUBLIC TRANSPORTATION
ASSISTANCE TAX LICENSE
SALES TAX EXEMPT STATUS
SMALL GAMES OF CHANCE LIC./CERT.
SALES, USE, HOTEL OCCUPANCY
TAX LICENSE
TRANSIENT VENDOR CERTIFICATE
UNEMPLOYMENT COMPENSATION
USE TAX
VEHICLE RENTAL TAX
WHOLESALER CERTIFICATE
WORKERS’ COMPENSATION COVERAGE
SECTION 4 – AUTHORIZED SIGNATURE
I, (WE) THE UNDERSIGNED, DECLARE UNDER THE PENALTIES OF PERJURY THAT THE STATEMENTS CONTAINED HEREIN ARE TRUE, CORRECT, AND COMPLETE.
AUTHORIZED SIGNATURE (ATTACH POWER OF ATTORNEY IF APPLICABLE)
DAYTIME TELEPHONE NUMBER
(
TYPE OR PRINT NAME
E-MAIL ADDRESS
TYPE OR PRINT PREPARER’S NAME
DAYTIME TELEPHONE NUMBER
(
TITLE
)
DATE
TITLE
E-MAIL ADDRESS
DATE
)
4
PA-100 8-01
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.
2.
3.
SOLE PROPRIETORSHIP (INDIVIDUAL)
CORPORATION (Sec. 11)
GOVERNMENT (Sec. 13)
PROFIT
YES
GENERAL PARTNERSHIP
LIMITED PARTNERSHIP
LIMITED LIABILITY PARTNERSHIP
ASSOCIATION
ESTATE
LIMITED LIABILITY COMPANY
STATE WHERE CHARTERED
BUSINESS TRUST
RESTRICTED PROFESSIONAL COMPANY
STATE WHERE CHARTERED
JOINT VENTURE PARTNERSHIP
NON-PROFIT
IS THE ENTERPRISE ORGANIZED FOR PROFIT OR NON-PROFIT?
NO
IS THE ENTERPRISE EXEMPT FROM TAXATION UNDER INTERNAL REVENUE CODE SECTION 501(C)(3)? IF YES, PROVIDE
A COPY OF THE ENTERPRISE'S EXEMPTION AUTHORIZATION LETTER FROM THE INTERNAL REVENUE SERVICE.
SECTION 6 – OWNERS, PARTNERS, SHAREHOLDERS, OFFICERS, AND RESPONSIBLE PARTY INFORMATION
PROVIDE THE FOLLOWING FOR ALL INDIVIDUAL AND/OR ENTERPRISE OWNERS, PARTNERS, SHAREHOLDERS, OFFICERS, AND RESPONSIBLE PARTIES. IF STOCK IS PUBLICLY
TRADED, PROVIDE THE FOLLOWING FOR ANY SHAREHOLDER WITH AN EQUITY POSITION OF 5% OR MORE. ADDITIONAL SPACE IS AVAILABLE IN SECTION 6A, PAGE 11.
1. NAME
5.
2. SOCIAL SECURITY NUMBER
OWNER
OFFICER
PARTNER
SHAREHOLDER
RESPONSIBLE PARTY
6. TITLE
7. EFFECTIVE DATE
OF TITLE
3. DATE OF BIRTH *
4. FEDERAL EIN
8. PERCENTAGE OF
OWNERSHIP
9. EFFECTIVE DATE OF
OWNERSHIP
%
10. HOME ADDRESS (street)
CITY/TOWN
11. THIS PERSON IS RESPONSIBLE TO REMIT/MAINTAIN:
SALES TAX
COUNTY
STATE
EMPLOYER WITHHOLDING TAX
ZIP CODE + 4
MOTOR FUEL TAXES
WORKERS’ 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 TO COMPLETE THIS SECTION. COMPLETE SECTION 17 FOR MULTIPLE ESTABLISHMENTS.
1. ENTER THE PERCENTAGE THAT EACH PA BUSINESS ACTIVITY REPRESENTS OF THE TOTAL RECEIPTS OR REVENUES AT THIS ESTABLISHMENT. LIST ALL PRODUCTS OR
SERVICES ASSOCIATED WITH EACH BUSINESS ACTIVITY. ENTER THE PERCENTAGE THAT THE PRODUCTS OR SERVICES REPRESENT OF THE TOTAL RECEIPTS OR
REVENUES AT THIS ESTABLISHMENT.
PA BUSINESS ACTIVITY
Accommodation & Food Services
Agriculture, Forestry, Fishing, & Hunting
Art, Entertainment, & Recreation Services
Communications/Information
Construction (must complete question 3)
Domestics (Private Households)
Educational Services
Finance
Health Care Services
Insurance
Management of Companies & Enterprises
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
%
PRODUCTS OR SERVICES
%
ADDITIONAL
PRODUCTS OR SERVICES
%
100%
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 PERCENTAGE OF CONSTRUCTION ACTIVITY THAT IS RESIDENTIAL AND/OR COMMERCIAL.
__________________ % RENOVATIVE = 100%
___________________ % NEW
+
__________________ % COMMERCIAL = 100%
___________________ % RESIDENTIAL
+
5
PA-100 8-01
DEPARTMENT USE ONLY
ENTERPRISE NAME
SECTION 8 – ESTABLISHMENT SALES INFORMATION
1.
YES
NO
IS THIS ESTABLISHMENT SELLING TAXABLE PRODUCTS OR OFFERING TAXABLE SERVICES TO CONSUMERS FROM A LOCATION
IN PENNSYLVANIA? IF YES, COMPLETE SECTION 18.
2.
YES
NO
IS THIS ESTABLISHMENT SELLING CIGARETTES IN PENNSYLVANIA? IF YES, COMPLETE SECTIONS 18 AND 19.
3. LIST EACH COUNTY IN PENNSYLVANIA WHERE THIS ESTABLISHMENT IS CONDUCTING TAXABLE SALES ACTIVITY(IES).
COUNTY
COUNTY
COUNTY
COUNTY
COUNTY
COUNTY
ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY.
SECTION 9 – ESTABLISHMENT EMPLOYMENT INFORMATION
PART 1
1.
YES
NO
DOES THIS ESTABLISHMENT EMPLOY INDIVIDUALS WHO WORK IN PENNSYLVANIA? IF YES, INDICATE:
a. DATE WAGES FIRST PAID (MM/DD/YYYY) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b.
DATE WAGES RESUMED FOLLOWING A BREAK IN EMPLOYMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c.
TOTAL NUMBER OF EMPLOYEES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
d.
NUMBER OF EMPLOYEES PRIMARILY WORKING IN NEW BUILDING OR INFRASTRUCTURE . . . . . . . . . . . . . . .
e.
NUMBER OF EMPLOYEES PRIMARILY WORKING IN REMODELING CONSTRUCTION . . . . . . . . . . . . . . . . . . . . .
f.
ESTIMATED GROSS WAGES PER QUARTER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
g.
NAME OF WORKERS’ COMPENSATION INSURANCE COMPANY
.00
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 . . . . . . . . . . . . . . . . . . . . . . . . . .
b.
THIS ESTABLISHMENT HAS ZERO EMPLOYEES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c.
THIS ESTABLISHMENT RECEIVED APPROVAL TO SELF-INSURE BY THE PA BUREAU OF
WORKERS’ COMPENSATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
IF ITEM 3c. IS CHECKED, PROVIDE PA WORKERS’ COMPENSATION BUREAU CODE
2.
3.
YES
YES
NO
DOES THIS ESTABLISHMENT EMPLOY PA RESIDENTS WHO WORK OUTSIDE OF PENNSYLVANIA?
IF YES, INDICATE:
a.
DATE WAGES FIRST PAID (MM/DD/YYYY) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b.
DATE WAGES RESUMED FOLLOWING A BREAK IN EMPLOYMENT . . . . . . . . . . . . . . . . . . . . . . . .
c.
ESTIMATED GROSS WAGES PER QUARTER.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
.00
NO
DOES THIS ESTABLISHMENT PAY REMUNERATION FOR SERVICES TO PERSONS YOU DO NOT CONSIDER EMPLOYEES?
IF YES, EXPLAIN THE SERVICES PERFORMED
NO
IS THIS REGISTRATION A RESULT OF A TAXABLE DISTRIBUTION FROM A BENEFIT TRUST, DEFERRED PAYMENT, OR RETIREMENT PLAN
FOR PA RESIDENTS?
PART 2
1.
YES
IF YES, INDICATE:
a.
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.
YES
NO
DID THE ENTERPRISE ACQUIRE 51% OR MORE OF ANY CLASS OF THE PA ASSETS OF ANOTHER ENTERPRISE? SEE THE CLASS OF ASSETS
LISTED BELOW.
2.
YES
NO
DID THE ENTERPRISE ACQUIRE 51% OR MORE OF THE TOTAL ASSETS OF ANOTHER ENTERPRISE?
IF THE ANSWER TO EITHER QUESTION IS YES, PROVIDE THE FOLLOWING INFORMATION ABOUT THE SELLER/TRANSFEROR.
3. SELLER/TRANSFEROR NAME
4. FEDERAL EIN
5. SELLER/TRANSFEROR STREET ADDRESS
6. DATE ASSETS ACQUIRED
CITY/TOWN
STATE
ZIP CODE + 4
7. ASSETS ACQUIRED:
ACCOUNTS RECEIVABLE
CONTRACTS
CUSTOMERS/CLIENTS
EQUIPMENT
FIXTURES
FURNITURE
INVENTORY
LEASES
MACHINERY
NAME AND/OR GOODWILL
REAL ESTATE
OTHER
IMPORTANT: IF, IN ADDITION TO ACQUIRING ASSETS IN BULK, THE ENTERPRISE ALSO ACQUIRED ALL OR PART OF A PREDECESSOR'S BUSINESS, SECTION 14 MUST BE COMPLETED.
6
PA-100 8-01
DEPARTMENT USE ONLY
ENTERPRISE NAME
SECTION 11 – CORPORATION INFORMATION
1. DATE OF INCORPORATION
5.
YES
NO
2. STATE OF INCORPORATION
3. CERTIFICATE OF AUTHORITY DATE
(NON-PA CORP.)
4. COUNTRY OF INCORPORATION
IS THIS CORPORATION'S STOCK PUBLICLY TRADED?
6. CHECK THE APPROPRIATE BOX(ES) TO DESCRIBE THIS CORPORATION:
CORPORATION:
7. S-CORPORATION:
PROFESSIONAL
MANAGEMENT
PENNSYLVANIA
STOCK
NON-STOCK
FEDERAL
BANK:
COOPERATIVE
STATE
MUTUAL THRIFT:
FEDERAL
STATE
INSURANCE
FEDERAL
COMPANY:
PA
NON-PA
STATUTORY CLOSE
(REV-1640 MUST BE FILED TO ELECT PENNSYLVANIA S STATUS.)
SECTION 12 – REPORTING & PAYMENT METHODS
1. THE DEPARTMENT OF REVENUE REQUIRES THAT ANY ENTERPRISE THAT MEETS THE $20,000 PAYMENT THRESHOLD REMIT PAYMENTS VIA ELECTRONIC FUNDS TRANSFER
(EFT). AN ENTERPRISE, REGARDLESS OF AMOUNT, MAY APPLY FOR EFT PAYMENT METHOD.
YES
DOES THIS ENTERPRISE MEET THE DEPARTMENT OF REVENUE’S REQUIREMENTS FOR EFT?
YES
NO
b.
NO
DOES THIS ENTERPRISE WANT TO PARTICIPATE IN THE DEPARTMENT OF REVENUE’S EFT PROGRAM?
2.
YES
NO
IF THIS ENTERPRISE IS A NON-PROFIT ORGANIZATION THAT IS EXEMPT UNDER IRS 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.
a.
3. THE DEPARTMENT OF LABOR & INDUSTRY REQUIRES THAT ANY ENTERPRISE WITH 250 OR MORE WAGE ENTRIES PER QUARTERLY REPORT, FILE THE WAGE INFORMATION
VIA MAGNETIC MEDIA. AN ENTERPRISE, REGARDLESS OF SIZE, MAY APPLY TO FILE THEIR WAGE INFORMATION VIA MAGNETIC MEDIA.
a.
YES
NO
DOES THIS ENTERPRISE MEET THE DEPARTMENT OF LABOR & INDUSTRY’S THRESHOLD FOR MAGNETIC MEDIA FILING?
b.
YES
NO
DOES THIS ENTERPRISE WANT TO RECEIVE INFORMATION ABOUT THE MAGNETIC MEDIA FILING METHOD?
INFORMATION ABOUT INTERNET FILING OPTIONS FOR PENNSYLVANIA BUSINESS TAXES CAN BE FOUND ON THE E-TIDES HOME PAGE AT www.etides.state.pa.us
SECTION 13 – GOVERNMENT STRUCTURE
1. IS THE ENTERPRISE A:
GOVERNMENT BODY
GOVERNMENT OWNED ENTERPRISE
GOVERNMENT & PRIVATE SECTOR
OWNED ENTERPRISE
DOMESTIC/USA
FOREIGN/NON-USA
MULTI-NATIONAL
BOROUGH
2. IS THE GOVERNMENT:
3. IF DOMESTIC, IS THE GOVERNMENT:
7
FEDERAL
STATE GOVERNOR'S JURISDICTION
STATE NON-GOVERNOR'S JURISDICTION
LOCAL:
COUNTY
CITY
TOWN
TOWNSHIP
SCHOOL DISTRICT
OTHER
PA-100 8-01
DEPARTMENT USE ONLY
ENTERPRISE NAME
SECTION 14 – PREDECESSOR/SUCCESSOR INFORMATION
COMPLETE THIS SECTION IF THE REGISTERING ENTERPRISE IS WHOLLY OR PARTIALLY SUCCEEDING A PREDECESSOR.
FOR ASSISTANCE, CONTACT THE NEAREST DEPARTMENT OF LABOR & INDUSTRY FIELD ACCOUNTING SERVICE OFFICE.
IF THE ENTERPRISE HAS MORE THAN ONE PREDECESSOR, PHOTOCOPY THIS PAGE TO PROVIDE THE FOLLOWING INFORMATION ABOUT EACH.
1. PREDECESSOR LEGAL NAME
2. PREDECESSOR PA UC ACCOUNT NUMBER
3. PREDECESSOR TRADE NAME
4. PREDECESSOR FEDERAL EIN
5. PREDECESSOR STREET ADDRESS
CITY/TOWN
6. SPECIFY HOW THE BUSINESS OPERATION WAS ACQUIRED:
7.
CONSOLIDATION
ACQUISITION DATE
GIFT
MERGER
STATE
ACQUISITION OF EXISTING OPERATION
IRC SEC. 338 ELECTION
ZIP CODE + 4
CHANGE IN LEGAL STRUCTURE
OTHER (SPECIFY)
8. PERCENTAGE OF THE PREDECESSOR'S TOTAL BUSINESS OPERATION (PA AND NON-PA) ACQUIRED
%
9. PERCENTAGE OF THE PREDECESSOR'S PA BUSINESS OPERATION 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 OPERATION THAT WAS ACQUIRED?
11. ASSETS ACQUIRED:
ACCOUNTS RECEIVABLE
CLIENTS/CUSTOMERS
CONTRACTS
FURNITURE AND FIXTURES
INVENTORIES
LEASES
MACHINERY AND EQUIPMENT
NAME AND/OR GOODWILL
REAL ESTATE
OTHER (SPECIFY)
12. YES
NO
HAS THE PREDECESSOR CEASED PAYING WAGES IN PA? IF YES, ENTER THE DATE PA WAGES CEASED,
IF KNOWN.
13. YES
NO
HAS THE PREDECESSOR CEASED OPERATIONS IN PA? IF YES, ENTER THE DATE PA OPERATIONS CEASED,
IF KNOWN.
IF NO, DESCRIBE THE PREDECESSOR'S PRESENT PA BUSINESS ACTIVITY, IF KNOWN.
14. AT THE TIME OF TRANSFER FROM THE PREDECESSOR ENTERPRISE TO THE REGISTERING ENTERPRISE:
a.
YES
NO
WERE ANY OF THE OWNERS, SHAREHOLDERS (5% OR GREATER), PARTNERS, OFFICERS, OR DIRECTORS OF THE PREDECESSOR
OR OF ANY AFFILIATE, SUBSIDIARY OR PARENT CORPORATION OF THE PREDECESSOR ALSO OWNERS, SHAREHOLDERS (5% OR
GREATER), PARTNERS, OFFICERS, OR DIRECTORS OF THE REGISTERING ENTERPRISE OR OF ANY AFFILIATE, SUBSIDIARY OR
PARENT CORPORATION OF THE REGISTERING ENTERPRISE?
b.
YES
NO
WAS THE PREDECESSOR, OR ANY AFFILIATE, SUBSIDIARY OR PARENT CORPORATION OF THE PREDECESSOR, AN OWNER,
SHAREHOLDER (5% OR GREATER), OR PARTNER IN THE REGISTERING ENTERPRISE?
c.
YES
NO
WAS THE REGISTERING ENTERPRISE, OR ANY AFFILIATE, SUBSIDIARY OR PARENT CORPORATION OF THE REGISTERING
ENTERPRISE, AN OWNER, SHAREHOLDER (5% OR GREATER), OR PARTNER IN THE PREDECESSOR?
IF THE ANSWER TO ANY OF THE QUESTIONS IN 14 IS YES, PROVIDE THE FOLLOWING INFORMATION. ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY.
IDENTIFY THOSE PERSONS AND ENTITIES BY THEIR FULL NAME;
DESCRIBE THEIR RELATIONSHIP TO THE PREDECESSOR AND ANY AFFILIATE, SUBSIDIARY AND PARENT CORPORATION OF THE PREDECESSOR; AND
DESCRIBE THEIR RELATIONSHIP TO THE REGISTERING ENTERPRISE AND ANY AFFILIATE, SUBSIDIARY AND PARENT CORPORATION OF THE REGISTERING ENTERPRISE.
THE REGISTERING ENTERPRISE MAY APPLY FOR A TRANSFER IN WHOLE OR IN PART OF THE PREDECESSOR'S UNEMPLOYMENT COMPENSATION (UC)
EXPERIENCE RECORD AND RESERVE ACCOUNT BALANCE, IF THE REGISTERING ENTERPRISE IS CONTINUING ESSENTIALLY THE SAME BUSINESS
ACTIVITY AS THE PREDECESSOR AND BOTH PROVIDED PA COVERED EMPLOYMENT. COMPLETE SECTION 15 AND, IF APPLICABLE, SECTION 16.
NOTE:
A REGISTERING ENTERPRISE MAY APPLY THE UC TAXABLE WAGES PAID BY A PREDECESSOR TOWARD THE REGISTERING ENTERPRISE’S UC TAXABLE WAGE BASE FOR THE CALENDAR YEAR OF
ACQUISITION WITHOUT TRANSFERRING THE PREDECESSOR'S EXPERIENCE RECORD AND RESERVE ACCOUNT BALANCE.
8
PA-100 8-01
DEPARTMENT USE ONLY
ENTERPRISE NAME
SECTION 15 – APPLICATION FOR PA UC EXPERIENCE RECORD AND RESERVE ACCOUNT
BALANCE OF PREDECESSOR
A REGISTERING ENTERPRISE MAY APPLY THE UNEMPLOYMENT COMPENSATION (UC) TAXABLE WAGES PAID BY A PREDECESSOR TOWARD THE REGISTERING
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.
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 ENTERPRISE ACQUIRED ONLY PART OF THE PREDECESSOR'S PENNSYLVANIA (PA) BUSINESS OPERATION AND IS MAKING APPLICATION FOR THE TRANSFER OF A PORTION OF THE PREDECESSOR'S EXPERIENCE RECORD AND RESERVE ACCOUNT BALANCE.
COMPLETE REPLACEMENT UC-2A FOR PARTIAL TRANSFER (FORM UC-252). THE PREDECESSOR'S PA PAYROLL RECORDS FOR THE TWO YEARS PRIOR TO THE QUARTER OF
THE TRANSFER AND/OR ACQUISITION MUST REMAIN AVAILABLE TO THE REGISTERING ENTERPRISE TO ENABLE THE REGISTERING ENTERPRISE TO PROVIDE REQUIRED
INFORMATION REGARDING SEPARATED AND/OR TRANSFERRED EMPLOYEES.
UNEMPLOYMENT COMPENSATION (UC) TAXABLE WAGES ARE THOSE WAGES THAT DO NOT EXCEED THE UC TAXABLE WAGE BASE APPLICABLE TO A GIVEN CALENDAR YEAR.
1. DATE WAGES FIRST PAID BY PREDECESSOR OR PRE-PREDECESSOR(S) IN THE PART OF THE PA BUSINESS OPERATION TRANSFERRED (ACQUIRED) FOR WHICH CONTRIBUTIONS WERE PAID UNDER THE PROVISIONS OF THE PA UC LAW.
DATE:
2. CHECKMARK THE CALENDAR QUARTERS IN THE YEAR OF
TRANSFER AND IN THE PRECEDING FIVE CALENDAR YEARS IN
WHICH PA UC CONTRIBUTIONS WERE PAID IN THE PART OF THE
PA BUSINESS OPERATION THAT WAS TRANSFERRED. ENTER A
ZERO IN EACH QUARTER WHEN NO CONTRIBUTION WAS DUE
AND PAYABLE IN THE PART TRANSFERRED.
YEAR________ YEAR________ YEAR________ YEAR________ YEAR________ YEAR________
OF TRANSFER
3. CHECKMARK THE CALENDAR QUARTERS IN THE YEAR OF
TRANSFER AND IN THE PRECEDING FIVE CALENDAR YEARS IN
WHICH PA UC CONTRIBUTIONS WERE PAID IN THE PART OF THE
PA BUSINESS OPERATION THAT WAS NOT TRANSFERRED.
ENTER A ZERO IN EACH QUARTER WHEN NO CONTRIBUTION
WAS DUE AND PAYABLE IN THE PART RETAINED.
YEAR________ YEAR________ YEAR________ YEAR________ YEAR________ YEAR________
OF TRANSFER
QUARTERS
1
2
3
QUARTERS
4
1
QUARTERS
1
2
3
2
3
QUARTERS
4
1
QUARTERS
4
1
2
3
2
3
4
QUARTERS
1
QUARTERS
4
1
2
3
4
2
3
4
QUARTERS
1
QUARTERS
1
2
3
4
2
3
4
QUARTERS
1
QUARTERS
1
2
3
4
2
3
4
QUARTERS
1
2
3
4
4b. IF THE PART OF THE PA BUSINESS OPERATION TRANSFERRED WAS NOT IN
EXISTENCE FOR THREE CALENDAR YEARS PRIOR TO THE YEAR OF THE
TRANSFER, ENTER THE PA TAXABLE PAYROLL FOR THE PERIOD OF ITS EXISTENCE TO DATE OF TRANSFER .
4a. PREDECESSOR'S PA UC TAXABLE PAYROLL IN THE PART OF THE PA BUSINESS
OPERATION TRANSFERRED FOR THE PERIOD OF THREE CALENDAR YEARS
PRIOR TO THE YEAR OF TRANSFER (ACQUISITION).
OR
$
5. PREDECESSOR'S ENTIRE PA UC TAXABLE PAYROLL FOR SAME PERIOD
INDICATED IN ITEMS 4a OR 4b.
$
9
$
6. PREDECESSOR'S ENTIRE PA UC TAXABLE PAYROLL FOR THE PERIOD FROM
THE BEGINNING OF THE QUARTER OF TRANSFER TO THE DATE OF TRANSFER.
$
PA-100 8-01
DEPARTMENT USE ONLY
ENTERPRISE NAME
SECTION 17 – MULTIPLE ESTABLISHMENT INFORMATION
COMPLETE THIS SECTION FOR EACH ADDITIONAL ESTABLISHMENT CONDUCTING BUSINESS IN PA OR EMPLOYING PA RESIDENTS. PHOTOCOPY THIS SECTION AS NECESSARY.
.
PART 1
ESTABLISHMENT INFORMATION
1. ESTABLISHMENT NAME (doing business as)
2. DATE OF FIRST OPERATIONS
3. TELEPHONE NUMBER
(
4. STREET ADDRESS
CITY/TOWN
5. SCHOOL DISTRICT
PART 2
COUNTY
STATE
)
ZIP CODE + 4
6. MUNICIPALITY
ESTABLISHMENT BUSINESS ACTIVITY INFORMATION
REFER TO THE INSTRUCTIONS TO COMPLETE THIS SECTION. COMPLETE SECTION 17 FOR MULTIPLE ESTABLISHMENTS.
1. ENTER THE PERCENTAGE THAT EACH PA BUSINESS ACTIVITY REPRESENTS OF THE TOTAL RECEIPTS OR REVENUES AT THIS ESTABLISHMENT. LIST ALL PRODUCTS OR
SERVICES ASSOCIATED WITH EACH BUSINESS ACTIVITY. ENTER THE PERCENTAGE THAT THE PRODUCTS OR SERVICES REPRESENT OF THE TOTAL RECEIPTS OR
REVENUES AT THIS ESTABLISHMENT.
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 of Companies & Enterprises
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 PA RECEIPTS OR REVENUES OF THE ENTERPRISE.
___________________ %
3. ESTABLISHMENTS ENGAGED IN CONSTRUCTION MUST ENTER THE PERCENTAGE OF CONSTRUCTION ACTIVITY THAT IS NEW AND/OR RENOVATIVE AND THE PERCENTAGE OF CONSTRUCTION ACTIVITY THAT IS RESIDENTIAL AND/OR COMMERCIAL.
___________________ % NEW
+
__________________ % RENOVATIVE = 100%
___________________ % RESIDENTIAL
+
__________________ % COMMERCIAL = 100%
10
PA-100 8-01
DEPARTMENT USE ONLY
ENTERPRISE NAME
PART 3
ESTABLISHMENT SALES INFORMATION
1.
YES
NO
IS THIS ESTABLISHMENT SELLING TAXABLE PRODUCTS OR OFFERING TAXABLE SERVICES TO CONSUMERS FROM A LOCATION
IN PENNSYLVANIA? IF YES, COMPLETE SECTION 18.
2.
YES
NO
IS THIS ESTABLISHMENT SELLING CIGARETTES IN PENNSYLVANIA? IF YES, COMPLETE SECTIONS 18 AND 19.
3. LIST EACH COUNTY IN PENNSYLVANIA WHERE THIS ESTABLISHMENT IS CONDUCTING TAXABLE SALES ACTIVITY(IES).
COUNTY
COUNTY
COUNTY
COUNTY
COUNTY
COUNTY
ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY.
ESTABLISHMENT EMPLOYMENT INFORMATION
PART 4a
1.
YES
NO
DOES THIS ESTABLISHMENT EMPLOY INDIVIDUALS WHO WORK IN PENNSYLVANIA? IF YES, INDICATE:
a.
2.
YES
NO
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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
YES
NO
.00
DOES THIS ESTABLISHMENT EMPLOY PA RESIDENTS WHO WORK OUTSIDE OF PENNSYLVANIA?
IF YES, INDICATE:
a.
3.
DATE WAGES FIRST PAID (MM/DD/YYYY) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b.
DATE WAGES FIRST PAID (MM/DD/YYYY) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b.
DATE WAGES RESUMED FOLLOWING A BREAK IN EMPLOYMENT . . . . . . . . . . . . . . . . . . . . . . .
c.
ESTIMATED GROSS WAGES PER QUARTER. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
.00
DOES THIS ESTABLISHMENT PAY REMUNERATION FOR SERVICES TO PERSONS YOU DO NOT CONSIDER EMPLOYEES?
IF YES, EXPLAIN THE SERVICES PERFORMED
PART 4b
1.
YES
NO
IS THIS REGISTRATION A RESULT OF A TAXABLE DISTRIBUTION FROM A BENEFIT TRUST, DEFERRED PAYMENT OR RETIREMENT
PLAN FOR PA RESIDENTS? IF YES, INDICATE:
a. DATE BENEFITS FIRST PAID (MM/DD/YYYY) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b.
.00
ESTIMATED BENEFITS PAID PER QUARTER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$
SECTION 6A – ADDITIONAL OWNERS, PARTNERS, SHAREHOLDERS, OFFICERS, AND
RESPONSIBLE PARTY INFORMATION
PROVIDE THE FOLLOWING FOR ALL INDIVIDUAL AND/OR ENTERPRISE OWNERS, PARTNERS, SHAREHOLDERS, OFFICERS, AND RESPONSIBLE PARTIES. IF STOCK IS PUBLICLY
TRADED, PROVIDE THE FOLLOWING FOR ANY SHAREHOLDER WITH AN EQUITY POSITION OF 5% OR MORE. PHOTOCOPY IF ADDITIONAL SPACE IS NEEDED.
1. NAME
OWNER
OFFICER
PARTNER
SHAREHOLDER
RESPONSIBLE PARTY
10. HOME ADDRESS (street)
5.
2. SOCIAL SECURITY NUMBER
6. TITLE
7. EFFECTIVE DATE
OF TITLE
1. NAME
OWNER
OFFICER
PARTNER
SHAREHOLDER
RESPONSIBLE PARTY
4. FEDERAL EIN
8. PERCENTAGE OF
OWNERSHIP
9. EFFECTIVE DATE OF
OWNERSHIP
%
CITY/TOWN
11. THIS PERSON IS RESPONSIBLE TO REMIT/MAINTAIN:
5.
3. DATE OF BIRTH *
SALES TAX
COUNTY
EMPLOYER WITHHOLDING TAX
ZIP CODE + 4
MOTOR FUEL TAXES
WORKERS’ COMPENSATION COVERAGE
2. SOCIAL SECURITY NUMBER
6. TITLE
7. EFFECTIVE DATE
OF TITLE
3. DATE OF BIRTH *
4. FEDERAL EIN
8. PERCENTAGE OF
OWNERSHIP
9. EFFECTIVE DATE OF
OWNERSHIP
%
10. HOME ADDRESS (street)
11. THIS PERSON IS RESPONSIBLE TO REMIT/MAINTAIN:
STATE
CITY/TOWN
SALES TAX
COUNTY
EMPLOYER WITHHOLDING TAX
STATE
ZIP CODE + 4
MOTOR FUEL TAXES
WORKERS’ 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 8-01
DEPARTMENT USE ONLY
ENTERPRISE NAME
SECTION 18 – SALES USE AND HOTEL OCCUPANCY TAX LICENSE, PUBLIC TRANSPORTATION ASSISTANCE TAX
LICENSE, VEHICLE RENTAL TAX, TRANSIENT VENDOR CERTIFICATE, PROMOTER LICENSE, OR WHOLESALER CERTIFICATE
PART 1
SALES USE AND HOTEL OCCUPANCY TAX, PUBLIC TRANSPORTATION ASSISTANCE TAX,
VEHICLE RENTAL TAX, OR WHOLESALER CERTIFICATE
ENTERPRISES APPLYING FOR A SALES, USE AND HOTEL OCCUPANCY TAX LICENSE, PUBLIC TRANSPORTATION ASSISTANCE TAX LICENSE, VEHICLE RENTAL TAX, AND/OR
WHOLESALER CERTIFICATE.
COMPLETE PART 1. SALES TAX COLLECTED MUST BE SEGREGATED FROM OTHER FUNDS AND MUST REMAIN IN THE COMMONWEALTH OF PENNSYLVANIA UNTIL REMITTED
TO THE DEPARTMENT OF REVENUE.
IF THE ENTERPRISE IS:
SELLING TAXABLE PRODUCTS OR SERVICES TO CONSUMERS IN PENNSYLVANIA, ENTER DATE OF FIRST TAXABLE SALE
PURCHASING TAXABLE PRODUCTS OR SERVICES FOR ITS OWN USE IN PENNSYLVANIA AND INCURRING NO SALES TAX,
ENTER DATE OF FIRST PURCHASE
SELLING NEW TIRES TO CONSUMERS IN PENNSYLVANIA, ENTER DATE OF FIRST SALE
LEASING OR RENTING MOTOR VEHICLES, ENTER DATE OF FIRST LEASE OR RENTAL
RENTING FIVE OR MORE MOTOR VEHICLES, ENTER DATE OF FIRST RENTAL
CONDUCTING RETAIL SALES IN PENNSYLVANIA AND NOT MAINTAINING A PERMANENT LOCATION IN PA, ENTER DATE OF FIRST
TAXABLE SALE
(COMPLETE PART 2)
ACTIVELY PROMOTING SHOWS IN PENNSYLVANIA WHERE TAXABLE PRODUCTS WILL BE OFFERED FOR RETAIL SALE, ENTER
DATE OF FIRST SHOW
. (COMPLETE PART 3)
ENGAGED SOLELY IN THE SALE OF TANGIBLE PERSONAL PROPERTY AND/OR SERVICES FOR RESALE OR RENTAL.
ENTER DATE OF FIRST PURCHASE.
PART 2
TRANSIENT VENDOR CERTIFICATE
IF THE ENTERPRISE PARTICIPATES IN ANY SHOWS OTHER THAN THOSE LISTED, PROVIDE THE NAME(S) OF THE SHOW(S) AND INFORMATION ABOUT THE SHOW(S) TO THE
DEPARTMENT OF REVENUE AT LEAST 10 DAYS PRIOR TO THE SHOW.
PROVIDE THE FOLLOWING INFORMATION FOR EACH SHOW:
1. PROMOTER NUMBER
2. SHOW NAME
3. COUNTY
4. SHOW ADDRESS (STREET, CITY, STATE, ZIP)
5. START DATE
1. PROMOTER NUMBER
3. COUNTY
2. SHOW NAME
4. SHOW ADDRESS (STREET, CITY, STATE, ZIP)
6. END DATE
5. START DATE
6. END DATE
3. START DATE
4. END DATE
ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY.
PART 3
PROMOTER LICENSE
PROVIDE THE FOLLOWING INFORMATION FOR EACH SHOW:
1. SHOW NAME
2. TYPE OF SHOW
5. SHOW ADDRESS (STREET, CITY, STATE, ZIP)
1. SHOW NAME
5. SHOW ADDRESS (STREET, CITY, STATE, ZIP)
6. COUNTY
2. TYPE OF SHOW
7. NBR OF VENDORS
3. START DATE
6. COUNTY
4. END DATE
7. NBR OF VENDORS
ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY.
12
PA-100 8-01
DEPARTMENT USE ONLY
ENTERPRISE NAME
SECTION 19 – CIGARETTE DEALER’S LICENSE
LICENSE TYPE
PART 1
CHECK THE APPROPRIATE BOX(ES) TO INDICATE LICENSE TYPE REQUESTED. A SEPARATE LICENSE MUST BE OBTAINED FOR EACH ESTABLISHMENT THAT SELLS CIGARETTES
(CSA, WHOLESALE, RETAIL, AND/OR VENDING). A SEPARATE DECAL MUST BE PURCHASED FOR EACH VENDING MACHINE LOCATION. A CHECK OR MONEY ORDER MUST BE
SUBMITTED WITH THIS APPLICATION.
LICENSE TYPE
NUMBER
FEE
AMOUNT REMITTED
RETAIL OVER-THE-COUNTER
_____________________
@ $
25 EACH LOCATION
$
VENDING MACHINE (ATTACH A LIST OF LOCATIONS)
_____________________
@ $
25 EACH DECAL
$
WHOLESALER
_____________________
@ $
500 EACH LICENSE
$
CIGARETTE STAMPING AGENT AND WHOLESALER
_____________________
@ $
1,500 EACH LICENSE
$
TOTAL AMOUNT REMITTED
$
MAKE CHECKS PAYABLE TO PA DEPARTMENT OF REVENUE
CIGARETTE WHOLESALER
PART 2
LIST CIGARETTE STORAGE LOCATION(S) (P.O. BOXES ARE NOT ACCEPTABLE).
1. STREET ADDRESS
CITY/TOWN
2.
YES
COUNTY
NO
STATE
ZIP CODE + 4
HAS ANY OWNER, PARTNER, OFFICER, DIRECTOR, OR MAJOR STOCKHOLDER BEEN CONVICTED OF ANY VIOLATION OF THE
PENNSYLVANIA CIGARETTE TAX ACT OR ANY MISDEMEANOR OR FELONY?
IF YES, LIST ALL CONVICTIONS WITHIN THE PREVIOUS 10 YEAR PERIOD. ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY.
3. THE APPLICANT HAS COMPLIED WITH ARTICLE II-A OF THE CIGARETTE SALES AND LICENSING ACT. UNDER PENALTY OF PERJURY, OF ADHERENCE TO STATE
PRESUMPTIVE MINIMUM PRICES OR APPROVAL TO SELL AT A DIFFERENT PRICE, IN ACCORDANCE WITH THE ACT:
CIGARETTES WILL BE SOLD AT OR ABOVE THE PRESUMPTIVE MINIMUM PRICE.
CIGARETTES WILL BE SOLD AT AN APPROVED MINIMUM PRICE.
CIGARETTE STAMPING AGENT
PART 3
1.
YES
IF YES, LIST STATES:
13
NO
DOES THE ENTERPRISE PURCHASE OR SELL ANY CIGARETTES WHICH ARE NOT PA STAMPED?
PA-100 8-01
DEPARTMENT USE ONLY
ENTERPRISE NAME
SECTION 20 – SMALL GAMES OF CHANCE LICENSE/CERTIFICATE
PART 1
DISTRIBUTOR AND/OR MANUFACTURER
TO BE COMPLETED BY ALL APPLICANTS (DISTRIBUTOR AND/OR MANUFACTURER)
APPLICANTS MUST SUBMIT A COPY OF THE CERTIFICATE OF INCORPORATION, ARTICLES OF INCORPORATION, CERTIFICATE OF AUTHORITY (NON-PA CORPORATIONS), BYLAWS, CONSTITUTION, OR FICTITIOUS NAME REGISTRATION.
APPLICANTS FOR A MANUFACTURER CERTIFICATE MUST SUBMIT A COPY OF THE COMPANY LOGO(S).
1.
CHECK APPROPRIATE BOX(ES) TO INDICATE TYPE OF LICENSE/CERTIFICATE REQUESTED
LICENSE/CERTIFICATE TYPE
FEE
AMOUNT REMITTED
DISTRIBUTOR LICENSE
$ 1,000
$
MANUFACTURER REGISTRATION CERTIFICATE
$ 2,000
$
REPLACEMENT LICENSE
$ 0100
$
REPLACEMENT CERTIFICATE
$ 0100
$
$00010
$
NUMBER OF BACKGROUND INVESTIGATIONS FOR OWNERS/OFFICERS, ETC. _____________
@
TOTAL AMOUNT REMITTED
$
MAKE CHECKS PAYABLE TO PA DEPARTMENT OF REVENUE
IF THE DEPARTMENT DENIES AN APPLICATION, A $100 APPLICATION PROCESSING FEE SHALL BE RETAINED BY THE DEPARTMENT. NO PART OF THE REGISTRATION OR
LICENSE FEE SHALL BE SUBJECT TO PRORATION. NO INVESTIGATION FEE SHALL BE REFUNDED.
2. DISTRIBUTORS AND MANUFACTURERS - PROVIDE THE FOLLOWING INFORMATION FOR THE COMMONWEALTH OF PA RESIDENT DESIGNEE. THE INDIVIDUAL MUST HAVE
PHYSICAL LOCATION WITHIN PA.
NAME
HOME ADDRESS (STREET)
CITY/TOWN
STATE
ZIP CODE + 4
TELEPHONE NBR.
(
3.
)
DISTRIBUTORS AND MANUFACTURERS - PROVIDE THE FOLLOWING INFORMATION FOR ALL INDIVIDUALS RESPONSIBLE FOR TAKING ORDERS AND MAKING SALES OF SMALL
GAMES OF CHANCE MERCHANDISE. IF AN INDIVIDUAL RESIDES IN PENNSYLVANIA, INDICATE IF COMMISSION OR NONCOMMISSION.
NAME
TITLE
SELLS FOR DISTRIBUTOR
SELLS FOR MANUFACTURER
HOME ADDRESS (STREET)
CITY/TOWN
STATE
NAME
TITLE
HOME ADDRESS (STREET)
CITY/TOWN
STATE
ZIP CODE + 4
COMMISSION
NONCOMMISSION
TELEPHONE NBR.
(
SELLS FOR DISTRIBUTOR
SELLS FOR MANUFACTURER
ZIP CODE + 4
)
COMMISSION
NONCOMMISSION
TELEPHONE NBR.
(
)
ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY
MANUFACTURERS ONLY MUST SUBMIT A CATALOG OF THE SMALL GAMES CHECKED BELOW. IF CATALOG IS UNAVAILABLE, PROVIDE NAME OF GAME(S) AND FORM
NUMBER(S), NUMBER OF TICKETS PER DEAL, HIGHEST INDIVIDUAL PRIZE VALUE, AND PERCENTAGE OF PAYOUT.
4. CHECK THE APPROPRIATE BOX(ES) TO INDICATE THE TYPES OF SMALL GAMES DISTRIBUTED OR MANUFACTURED.
DAILY DRAWINGS
PART 2
WEEKLY DRAWINGS
PULL-TABS
PUNCHBOARDS
RAFFLES
DISTRIBUTOR
LIST ALL SMALL GAMES OF CHANCE MANUFACTURERS WITH WHOM THE DISTRIBUTOR DOES BUSINESS.
MANUFACTURER’S LEGAL NAME
MANUFACTURER’S CERTIFICATE NBR.
STREET ADDRESS
MANUFACTURER’S LEGAL NAME
STREET ADDRESS
DISPENSING MACHINES
MCITY/TOWN
TELEPHONE NBR.
(
STATE
MANUFACTURER’S CERTIFICATE NBR.
MCITY/TOWN
)
ZIP CODE +4
TELEPHONE NBR.
(
STATE
)
ZIP CODE +4
ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY
14
SMALL GAMES OF CHANCE CERTIFICATION
PART 3
MUST BE COMPLETED BY ALL SMALL GAMES OF CHANCE APPLICANTS.
I CERTIFY THAT THE FOLLOWING TAX STATEMENTS ARE TRUE AND CORRECT
ALL PA STATE TAX REPORTS AND RETURNS HAVE BEEN FILED
ALL PA STATE TAXES HAVE BEEN PAID
ANY PA STATE TAXES OWED ARE SUBJECT TO TIMELY ADMINISTRATIVE OR JUDICIAL APPEAL; OR ANY DELINQUENT PA TAXES ARE SUBJECT TO DULY APPROVED
DEFERRED PAYMENT PLAN (COPY ENCLOSED).
I CERTIFY THAT NO OWNER, PARTNER, OFFICER, DIRECTOR, OR OTHER PERSON IN A SUPERVISORY OR MANAGEMENT POSITION, OR EMPLOYEE ELIGIBLE TO MAKE
SALES ON BEHALF OF THIS BUSINESS:
HAS BEEN CONVICTED OF A FELONY IN A STATE OR FEDERAL COURT WITHIN THE PAST FIVE YEARS
HAS BEEN CONVICTED WITHIN TEN YEARS OF THE DATE OF APPLICATION IN A STATE OR FEDERAL COURT OF A VIOLATION OF THE BINGO LAW OR OF THE LOCAL
OPTION SMALL GAMES OF CHANCE ACT, OR A GAMBLING-RELATED OFFENSE UNDER TITLE 18 OF THE PENNSYLVANIA CONSOLIDATED STATUTES OR OTHER
COMPARABLE STATE OR FEDERAL LAW
HAS NOT BEEN REJECTED IN ANY STATE FOR A DISTRIBUTOR LICENSE OR MANUFACTURER REGISTRATION CERTIFICATE, OR EQUIVALENT THERETO.
I DECLARE THAT I HAVE EXAMINED THIS APPLICATION, INCLUDING ALL ACCOMPANYING STATEMENTS, AND TO THE BEST OF MY KNOWLEDGE AND BELIEF IT IS TRUE,
CORRECT, AND COMPLETE.
NOTARY
AUTHORIZATION
SWORN AND SUBSCRIBED TO BEFORE ME THIS
_____________________ DAY OF _________________ , 20____
NOTARY PUBLIC
SIGNATURE OF AN OWNER, PARTNER, OFFICER,
OR DIRECTOR
SOCIAL SECURITY NUMBER
PRINT NAME
DATE
MY COMMISSION EXPIRES
TITLE
(
)
TELEPHONE NUMBER
NOTARY SEAL
15
CORPORATE SEAL
PA-100 8-01
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:
COMMON CARRIER
CONTRACT CARRIER
FOR HIRE CARRIER
PRIVATE CARRIER
LP GAS
INDICATE THE FUEL TYPES FOR PENNSYLVANIA BASED QUALIFIED MOTOR VEHICLES:
DIESEL
GASOLINE
ETHANOL/GASOHOL
CNG/LNG
MOTOR CARRIER ROAD TAX/IFTA VEHICLE DECAL REQUESTS
COMPLETE THE FOLLOWING FOR EACH QUALIFIED MOTOR VEHICLE YOU INTEND TO OPERATE IN PENNSYLVANIA DURING THE ENSUING CALENDAR YEAR.
NOTE: DECALS ARE $5.00 PER SET OF TWO.
1.
IFTA DECALS (NUMBER OF VEHICLES THAT TRAVEL IN PA AND OUT OF STATE)
2.
NON-IFTA DECALS (NUMBER OF VEHICLES THAT TRAVEL IN PA EXCLUSIVELY)
3. TOTAL DECALS REQUESTED (ADD LINES 1 AND 2)
4. TOTAL AMOUNT DUE (MULTIPLY LINE 3 BY $5)
$
REMITTANCE SUBMITTED:
5.
AUTHORIZED ADJUSTMENT (ATTACH ORIGINAL CREDIT NOTICE)
$
6. CHECK OR MONEY ORDER AMOUNT
$
MAKE CHECKS PAYABLE TO PA DEPARTMENT OF REVENUE
CHECK THE APPROPRIATE BOX(ES) TO INDICATE THE JURISDICTION(S) WHERE:
COLUMN A – QUALIFIED MOTOR VEHICLES ARE OPERATED
COLUMN B – BULK STORAGE OF DIESEL FUEL IS MAINTAINED
A B
C D
A B
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
– ALASKA
– ALABAMA
– ARKANSAS
– ARIZONA
– CALIFORNIA
– COLORADO
– CONNECTICUT
– DIST. OF COLUMBIA
– DELAWARE
– FLORIDA
– GEORGIA
– HAWAII
– IOWA
C D
C D
A B
AB – ALBERTA
BC – BRITISH COLUMBIA
MB – MANITOBA
PART 2
A B
ID –
IL –
IN –
KS –
KY –
LA –
MA –
MD –
ME –
MI –
MN –
MO –
MS –
COLUMN C – BULK STORAGE FOR GASOLINE IS MAINTAINED
COLUMN D – BULK STORAGE OF ANY OTHER MOTOR FUEL IS MAINTAINED
IDAHO
ILLINOIS
INDIANA
KANSAS
KENTUCKY
LOUISIANA
MASSACHUSETTS
MARYLAND
MAINE
MICHIGAN
MINNESOTA
MISSOURI
MISSISSIPPI
C D
A B
C D
A B
NB – NEW BRUNSWICK
NF – NEWFOUNDLAND
NS – NOVA SCOTIA
MT –
NC –
ND –
NE –
NH –
NJ –
NM –
NV –
NY –
OH –
OK –
OR –
PA –
MONTANA
NORTH CAROLINA
NORTH DAKOTA
NEBRASKA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEVADA
NEW YORK
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
C D
A B
C D
A B
NT – N W TERRITORY
ON – ONTARIO
PE – PRINCE EDWARD IS.
RI –
SC –
SD –
TN –
TX –
UT –
VA –
VT –
WA –
WI –
WV –
WY –
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VIRGINIA
VERMONT
WASHINGTON
WISCONSIN
WEST VIRGINIA
WYOMING
C D
PQ – QUEBEC
SK – SASKATCHEWAN
YT - YUKON TERRITORY
FUELS
CHECK THE APPROPRIATE BOX(ES) IF THE ENTERPRISE WILL SELL, USE, OR TRANSPORT ANY FUELS IN PENNSYLVANIA.
LIQUID FUELS AND FUELS TAX - YEARLY PERMIT REQUIRED BY WHOLESALE DISTRIBUTORS (E.G. ONE LICENSED TO HANDLE TAX-FREE LIQUID FUELS OR FUELS IN PA)
OR AN IMPORTER OR EXPORTER OF LIQUID FUELS OR FUELS.
ESTIMATED DATE OF FIRST TAX-FREE LIQUID FUELS PURCHASE OR SALE __________________________________
ALTERNATIVE FUELS TAX - YEARLY PERMIT REQUIRED BY ALTERNATIVE FUEL DEALER-USERS FOR THE REMISSION OF TAX ON ALTERNATIVE FUELS (HIGHWAY FUELS
OTHER THAN LIQUID FUELS OR FUELS) PLACED INTO THE SUPPLY TANK OF A MOTOR VEHICLE FOR USE ON PA HIGHWAYS.
ESTIMATED DATE OF FIRST FUELING OF VEHICLES __________________________________
PROVIDE A LIST OF ALL PA LOCATIONS WHERE LIQUID FUELS OR FUELS WILL BE SOLD.
STREET ADDRESS
CITY/TOWN
COUNTY
STATE
ZIP CODE + 4
STREET ADDRESS
COUNTY
STATE
ZIP CODE + 4
CITY/TOWN
ATTACH ADDITIONAL 8 1/2 x 11 SHEETS IF NECESSARY
16
PA-100 8-01
DEPARTMENT USE ONLY
ENTERPRISE NAME
SECTION 22 – SALES TAX EXEMPT STATUS FOR CHARITABLE AND RELIGIOUS ORGANIZATIONS
PART 1
ACT 55 OF 1997, KNOWN AS THE INSTITUTIONS OF PURELY PUBLIC CHARITY ACT, WAS SIGNED INTO LAW ON NOVEMBER 26, 1997. THIS LAW HAS CODIFIED THE REQUIREMENTS
AN INSTITUTION MUST MEET IN ORDER TO QUALIFY FOR EXEMPTION, OUTLINING FIVE CRITERIA THAT MUST BE MET. EACH INSTITUTION MUST: (1) ADVANCE A CHARITABLE
PURPOSE; (2) DONATE OR RENDER GRATUITOUSLY A SUBSTANTIAL PORTION OF ITS SERVICES; (3) BENEFIT A SUBSTANTIAL AND INDEFINITE CLASS OF PERSONS WHO ARE
LEGITIMATE SUBJECTS OF CHARITY; (4) RELIEVE THE GOVERNMENT OF SOME BURDEN; (5) OPERATE ENTIRELY FREE FROM PRIVATE PROFIT MOTIVE.
ORGANIZATIONS OF THE FOLLOWING TYPE DO NOT QUALIFY FOR EXEMPTION STATUS:
AN ASSOCIATION OF EMPLOYEES, THE MEMBERSHIP OF WHICH IS LIMITED TO THE EMPLOYEES OF A DESIGNATED ENTERPRISE
A LABOR ORGANIZATION
AN AGRICULTURAL OR HORTICULTURAL ORGANIZATION
A BUSINESS LEAGUE, CHAMBER OF COMMERCE, REAL ESTATE BOARD, BOARD OF TRADE, OR PROFESSIONAL SPORT LEAGUE
A CLUB ORGANIZED FOR PLEASURE OR RECREATION
A FRATERNAL BENEFICIARY SOCIETY, ORDER, OR ASSOCIATION.
TO APPLY OR RENEW SALES TAX EXEMPTION STATUS, A REV-72 APPLICATION MUST BE COMPLETED AND SUBMITTED ALONG WITH THE REQUIRED DOCUMENTATION. THIS
APPLICATION CAN BE OBTAINED BY COMPLETING THE BELOW FORM OR CALL (717) 783-5473. SERVICE FOR CUSTOMERS WITH SPECIAL HEARING AND/OR SPEAKING NEEDS
(TT ONLY) 1-800-447-3020.
IF THE ORGANIZATION CONDUCTS SALES ACTIVITIES AND IS NOT REGISTERED FOR COLLECTION OF 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
TO REQUEST SALES TAX EXEMPT STATUS APPLICATION
COMPLETE THIS FORM AND RETURN TO:
PA DEPARTMENT OF REVENUE
BUREAU OF BUSINESS TRUST FUND TAXES
DEPT. 280909
HARRISBURG, PA 17128-0909
17
ZIP CODE + 4
PA-100 8-01
SECTION 1 – REASON FOR THIS REGISTRATION
IF THE BUSINESS STRUCTURE IS:
USE THE:
An enterprise may select more than one reason for registration.
SOLE PROPRIETORSHIP
INDIVIDUAL OWNER’S NAME.
1.
CORPORATION
NAME AS SHOWN IN THE
ARTICLES OF INCORPORATION.
PARTNERSHIP
NAME AS SHOWN IN THE
PARTNERSHIP AGREEMENT.
ASSOCIATION
NAME AS SHOWN IN THE
ASSOCIATION AGREEMENT.
BUSINESS TRUST
NAME AS SHOWN IN THE
TRUST AGREEMENT.
ESTATE
LEGAL NAME OF THE ESTATE.
TRUST
NAME AS SHOWN IN THE
TRUST AGREEMENT.
LIMITED LIABILITY COMPANY
NAME AS SHOWN IN THE
ARTICLES OF ORGANIZATION.
RESTRICTED
PROFESSIONAL COMPANY
NAME AS SHOWN IN THE
ARTICLES OF ORGANIZATION.
GOVERNMENT
OFFICIAL/LEGAL NAME OF
THE ORGANIZATION.
2.
3.
New Registration: An enterprise never registered with
the PA Department of Revenue or the PA Department of
Labor & Industry must complete Sections 1 through 10
and additional sections as appropriate.
Adding Tax(es) and Service(s): A registered enterprise
adding tax(es) and service(s) must complete Sections 1
through 4 and additional sections as appropriate.
Reactivating Tax(es) and Service(s): A registered enterprise reactivating tax(es) and service(s) must complete Sections 1 through 4 and additional sections as appropriate.
4.
Adding Establishment(s): A registered enterprise adding
establishment location(s) must complete Sections 1 through
4 and Section 17, Multiple Establishment Information.
5.
Information Update: A registered enterprise providing
changes in demographic or other information must complete Sections 1 through 4 and additional sections as
appropriate.
6.
5.
Federal EIN: Enter the Federal Employer Identification Number (EIN) assigned to the enterprise by the Internal Revenue
Service. If the enterprise does not have an EIN, enter “N/A”.
If the enterprise has made application for an EIN, enter
“Applied For”.
6.
Enterprise Trade Name: Enter the name by which the enterprise is commonly known (doing business as, trading as, also
known as), if it is a name other than the legal name. If the
enterprise has a fictitious name registered with the PA
Department of State, enter it here. If the trade name is the
same as the legal name, enter “Same”.
Check the appropriate box to indicate the business operation of the enterprise. If yes:
7.
A newly formed enterprise must complete Sections 1
through 10, Section 14 and additional sections as
appropriate.
Enterprise Telephone Number: Enter the telephone number for the enterprise.
8.
Enterprise Street Address: Enter the physical location of
the enterprise. A post office box is not acceptable.
9.
Enterprise Mailing Address: Enter the address where the
enterprise prefers to receive mail, if at an address other
than the enterprise street address. A post office box is
acceptable. If the mailing address is the same as the enterprise street address, enter “Same”.
Did this Enterprise:
An enterprise acquiring the business operation of another
enterprise in whole or in part must complete Section 14,
Predecessor/Successor Information. The business operation can be acquired by consolidation, merger, gift, or
change in legal structure. A stock acquisition alone does
not constitute a transfer of the business operation.
A previously registered enterprise must complete Sections 1 through 4, 10, 14 and additional sections as
appropriate.
An enterprise requesting the PA Unemployment Compensation (UC) experience record and reserve account
balance of a predecessor (prior owner) must also complete Section 15, Application for PA UC Experience
Record and Reserve Account Balance of Predecessor.
SECTION 2 – ENTERPRISE INFORMATION
1.
2.
3.
4.
Date of First Operations: Enter the first date the enterprise conducted any activity. This includes start-up operations prior to opening for business.
Date of First Operations in PA: Enter the first date the
enterprise conducted any activity in PA or employed PA residents. This includes start-up operations prior to opening for
business.
Enterprise Fiscal Year End: Enter the month (January,
February, etc.) used by the enterprise to designate the end
of its accounting period.
Enterprise Legal Name: Enter the legal name of the
enterprise.
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 Employer Withholding and Unemployment Compensation Returns mailed to the address of a particular
payroll service.
10. Location of Enterprise Records: Enter the street address
where the enterprise records are kept. A post office box is
not acceptable. If the records are kept at the enterprise
street address, enter “Same”.
11. Establishment Name: Enter the name by which the establishment is known to the public; for example, the name on
the front of the store. If the same as the enterprise legal
name, enter “Same”.
12. Number of Establishments: Enter the number of establishments. If the enterprise has more than one establishment
conducting business in PA or employing PA residents, refer
to the instructions and complete Section 17, Multiple Establishment Information.
18
13. School District: Enter the school district where the establishment is located. If not a PA school district, enter “N/A”.
14. 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 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.
SECTION 3 – TAXES AND SERVICES
All shareholders (both individuals and enterprises) owning stock. If the stock is publicly traded, identify any
shareholder with an equity position of 5 percent or more.
Indicate the tax(es) and service(s) requested. Descriptions, additional requirements and sections to complete are on page(s) 2
and 3. Enter the previous account number(s) when reactivating tax(es) and service(s).
All officers of the corporation, association, or business
trust.
All individuals responsible for remitting trust fund taxes
or maintaining Workers’ Compensation Coverage.
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.
1.
Name: Enter the name(s) of the owner, partner, shareholder, officer, or responsible party of the enterprise. If the
owner is another enterprise, enter the legal name of the
enterprise.
2.
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.
Social Security Number: Enter the Social Security Number of the owner, partner, shareholder, officer, or responsible party.
3.
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.
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 designate if an owner, partner, officer, shareholder, or responsible party.
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 chartered.
The following forms of organization require the completion
of additional sections:
Corporation - Complete Section 11, Corporation Information.
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.
2.
Check the box to indicate if the enterprise is profit or nonprofit.
3.
If an enterprise is exempt under Section 501(c)(3) of the
Internal Revenue Code, and is also subject to the contribution 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.
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 PA law, 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 coverage when required may result in the personal assessment of a
responsible party, together with the possibility of criminal sanctions, if warranted.
See page 22 of the instructions for further explanations regarding contributory and reimbursement methods of making payments to the Unemployment Compensation Fund.
Space for additional information of owners, partners, shareholders, officers, and/or responsible parties can be found on page
11. Attach additional 8 1/2 X 11 sheets if necessary.
Government - Complete Section 13, Government Information.
19
SECTION 7 – ESTABLISHMENT BUSINESS ACTIVITY INFORMATION
ENTER THE PERCENTAGE THE PA BUSINESS ACTIVITY REPRESENTS OF THE TOTAL RECEIPTS OR REVENUES AT THIS ESTABLISHMENT. SPECIFY THE PRODUCTS AND/OR
SERVICES PROVIDED AT THIS ESTABLISHMENT AND ENTER THE PERCENTAGE EACH REPRESENTS OF THE TOTAL RECEIPTS OR REVENUES AT THIS ESTABLISHMENT.
EXAMPLE
PA BUSINESS ACTIVITY
%
PRODUCTS OR SERVICES
%
ADDITIONAL PRODUCTS OR SERVICES
%
CONSTRUCTION
MANUFACTURING
70
BUILDING SINGLE FAMILY HOMES
40
BUILDING APARTMENT BUILDINGS
30
30
WOOD PANELING
30
RETAIL TRADE
WHOLESALE TRADE
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
WITH LODGING AND/OR PREPARE MEALS, SNACKS, AND BEVERAGES FOR IMMEDIATE CONSUMPTION.
HOTELS
MOTELS
RV PARKS AND CAMPGROUNDS
VACATION CAMPS
FULL/LIMITED SERVICE
RESTAURANTS
MOBILE FOOD SERVICES
AND CATERERS
SPECIFY THE TYPE OF CROP GROWN, LIVESTOCK RAISED, FISH CAUGHT, AND FORESTRY WORK.
FOR EXAMPLE:
AGRICULTURE, FORESTRY, FISHING, AND HUNTING
ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE INVOLVED IN
GROWING CROPS, RAISING ANIMALS, HARVESTING FISH AND OTHER ANIMALS FROM
FARMS, RANCHES, OR ANIMALS' NATURAL HABITATS.
CROPS (CORN, WHEAT, APPLE)
AND WHETHER UNDER COVER
NURSERY/TREE
PRODUCTIONS
CATTLE RANCHING
DAIRY CATTLE AND MILK PRODUCTION
CHICKEN (EGG OR MEAT
TYPE)
TIMBER TRACTS, LOGGING
COMMERCIAL FISHING
HUNTING AND TRAPPING
SUPPORT ACTIVITIES FOR
CROP PRODUCTION/
FORESTRY (AERIAL DUSTING,
CULTIVATING SERVICES,
FOREST FIRE FIGHTING,
PEST CONTROL)
SPECIFY THE TYPE OF ART, ENTERTAINMENT, AND/OR RECREATION PROVIDED. FOR EXAMPLE:
ART, ENTERTAINMENT, AND RECREATION SERVICES
ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE OPERATING OR
PROVIDING SERVICES TO MEET VARIED CULTURAL, ENTERTAINMENT, AND RECREATIONAL INTERESTS OF THEIR PATRONS.
COMMUNICATIONS/INFORMATION
ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE DISTRIBUTING
INFORMATION AND CULTURAL PRODUCTS, PROVIDING THE MEANS TO TRANSMIT
OR DISTRIBUTE THESE PRODUCTS AS DATA OR COMMUNICATIONS, AND PROCESSING DATA.
THEATER COMPANIES
DANCE COMPANIES
MUSICAL GROUPS AND
ARTISTS
SPORTS TEAMS AND CLUBS
RACETRACKS
AGENTS AND MANAGERS
INDEPENDENT ARTISTS,
WRITERS, AND PERFORMERS
CASINOS
AMUSEMENT AND THEME
PARKS
RIDING STABLES
SPECIFY THE TYPE OF COMMUNICATION/INFORMATION ACTIVITY PERFORMED. FOR EXAMPLE:
PUBLISHING
RADIO/TELEVISION BROADPAGING
CASTING
(NEWSPAPER, DATABASE,
ON-LINE INFORMATION
SOFTWARE)
CABLE
SERVICES
MOTION PICTURE/VIDEO PROWIRED/WIRELESS TELECOMDUCTION
MUNICATIONS
LIBRARIES AND ARCHIVES
CONSTRUCTION
SPECIFY THE TYPE OF CONSTRUCTION. FOR EXAMPLE:
ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE PRIMARILY
ENGAGED IN THE CONSTRUCTION OF BUILDINGS OR ENGINEERING PROJECTS (E.G.
HIGHWAYS AND UTILITY SYSTEMS) INCLUDING SITE PREPARATION FOR NEW CONSTRUCTION AND SUBDIVIDING LAND FOR SALE AS BUILDING SITES. ACTIVITIES MAY
INCLUDE RESIDENTIAL/COMMERCIAL NEW WORK, ADDITIONS, ALTERATIONS, OR MAINTENANCE AND REPAIRS.
GENERAL OR OPERATIVE
BUILDERS (RESIDENTIAL OR
NONRESIDENTIAL)
INDUSTRIAL
ELECTRIC
HEAVY (BRIDGES, HIGHWAYS,
STREETS)
EXCAVATION
COMMERCIAL
PLUMBING
DOMESTICS
SPECIFY THE TYPE OF SERVICE. FOR EXAMPLE:
ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE COMPRISED OF
PRIVATE HOUSEHOLDS ENGAGED IN EMPLOYING WORKERS ON OR ABOUT THE
PREMISES IN ACTIVITIES PRIMARILY CONCERNED WITH THE OPERATION OF THE
HOUSEHOLD.
COOKS
NANNIES
GARDENERS
MAIDS
BUTLERS
CARETAKERS, AND OTHER
MAINTENANCE WORKERS
SPECIFY THE TYPE OF TRAINING FACILITY. FOR EXAMPLE:
EDUCATIONAL SERVICES
ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE PROVIDING
INSTRUCTION AND TRAINING IN A WIDE VARIETY OF SUBJECTS.
FINANCE
ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR INVOLVE THE CREATION, LIQUIDATION, OR CHANGE IN OWNERSHIP OF FINANCIAL ASSETS (FINANCIAL
TRANSACTIONS) AND/OR FACILITATING FINANCIAL TRANSACTIONS.
SCHOOLS
COLLEGES
UNIVERSITIES
BUSINESS/SECRETARIAL
SCHOOLS
TRAINING CENTERS (COMPUTER, FLIGHT, TECHNICAL AND
TRADE, APPRENTICESHIP,
COSMETOLOGY AND BARBER
SCHOOLS)
SPECIFY THE TYPE OF FINANCIAL INSTITUTION, CHARTER, AND TYPE OF FINANCIAL PRODUCTS AND
SERVICES OFFERED. FOR EXAMPLE:
COMMERCIAL BANKS
SALES FINANCING
INVESTMENT BANKING AND
SECURITIES DEALING
CREDIT UNIONS
REAL ESTATE LENDING
SPECIFY THE TYPE OF SERVICE PERFORMED. FOR EXAMPLE:
HEALTH CARE SERVICES
AMBULATORY HEALTH CARE
ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE PROVIDING
HEALTH CARE FOR INDIVIDUALS.
PHYSICIANS
DENTISTS
OPTOMETRISTS
MENTAL HEALTH
PRACTITIONERS
PODIATRISTS
OUTPATIENT CARE CENTERS
HMO MEDICAL CENTERS
KIDNEY DIALYSIS CENTERS
MEDICAL AND DIAGNOSTIC
LABORATORIES
HOME HEALTH
CARE SERVICES
ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE PRIMARILY
ENGAGED IN UNDERWRITING ANNUITIES AND INSURANCE POLICIES, OR FACILITATING SUCH UNDERWRITING BY SELLING INSURANCE POLICIES, AND BY PROVIDING
OTHER INSURANCE AND EMPLOYEE-BENEFIT RELATED SERVICES.
SPECIFY THE TYPE OF INSURANCE SOLD, AND SPECIFY IF THE INSURANCE IS UNDERWRITTEN BY
THE SAME ENTERPRISE. FOR EXAMPLE:
DIRECT LIFE
PROPERTY AND CASUALTY
CLAIMS ADJUSTING
HEALTH AND MEDICAL
TITLE
FUNDS AND TRUSTS
INSURANCE CARRIERS
REINSURANCE
MANAGEMENT OF COMPANIES AND ENTERPRISES
SPECIFY TYPE OF OFFICE. FOR EXAMPLE:
ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE HOLDING SECURITIES OF COMPANIES AND ENTERPRISES, FOR THE PURPOSE OF OWNING CONTROLLING INTEREST OR INFLUENCING THEIR MANAGEMENT DECISION, OR ADMINISTERING, OVERSEEING, AND MANAGING OTHER ESTABLISHMENTS OF THE SAME COMPANY OR ENTERPRISE AND NORMALLY UNDERTAKING THE STRATEGIC OR ORGANIZATIONAL PLANNING AND DECISION MAKING OF THE COMPANY OR ENTERPRISE.
OFFICES OF BANK HOLDING
COMPANIES
CENTRALIZED
ADMINISTRATIVE OFFICE
OFFICES OF OTHER HOLDING
COMPANIES
CORPORATE OFFICE
INSURANCE
DISTRICT AND REGIONAL
OFFICES
HEAD OFFICE
HOLDING COMPANY THAT
MANAGES, OR SUBSIDIARY
MANAGEMENT OFFICES
PROFESSIONAL EMPLOYEE
ORGAINZATION
20
PA BUSINESS ACTIVITY
MANUFACTURING
ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE INVOLVED IN THE
MECHANICAL, PHYSICAL, OR CHEMICAL TRANSFORMATION OF MATERIAL, SUBSTANCES, OR COMPONENTS INTO NEW PRODUCTS.
TYPICAL PRODUCTS OR SERVICES
SPECIFY THE PRODUCTS MANUFACTURED AND/OR TYPE OF PLANT & PRINCIPAL PROCESS USED.
FOR EXAMPLE:
FOOD (FROZEN OR
UNFROZEN, CANNED)
WOOD PRODUCTS (PALLETS,
DOORS, WINDOWS)
TEXTILES
PULP, PAPER, AND PAPERBOARD
CLOTHING/FOOTWEAR (MEN’S,
BOY’S, WOMEN’S, GIRL’S)
MINING, QUARRYING, OIL/GAS EXTRACTION
ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE EXTRACTING
NATURALLY OCCURRING MINERAL SOLIDS, SUCH AS COAL AND ORE; LIQUID MINERALS, SUCH AS CRUDE PETROLEUM; AND GASES, SUCH AS NATURAL GAS. THE
TERM MINING IS USED IN THE BROAD SENSE TO INCLUDE QUARRYING, WELL OPERATIONS, BENEFICIATING (E.G., CRUSHING, SCREENING, WASHING, AND FLOTATION),
AND OTHER PREPARATION CUSTOMARILY PERFORMED AT THE MINE SITE, OR AS
PART OF MINING ACTIVITY.
PRINTING (LITHOGRAPH
FLEXOGRAPHIC, GRAVURE,
QUICK, SCREEN, OR DIGITAL)
CHEMICAL
METAL (FERROUS, NONFERROUS, FABRICATED, FORGED,
OR STAMPED)
SPECIFY EACH MINERAL OR PRODUCT EXTRACTED, IF SERVICES, DESCRIBE SERVICE AND MINERAL
INVOLVED. FOR EXAMPLE:
OPERATING AND/OR DEVELOPING OIL AND GAS FIELDS OR
CRUDE PETROLEUM AND NATURAL GAS EXTRACTION
EXPLORATION FOR CRUDE
PETROLEUM, BITUMINOUS, OR
ANTHRACITE COAL MINING
(SURFACE OR UNDERGROUND)
METAL/NON- METAL ORES
GOLD, SILVER, STONE, SAND,
REFRACTORY
OTHER SERVICES (EXCEPT PUBLIC ADMINISTRATION)
SPECIFY THE TYPE OF SERVICE PROVIDED. FOR EXAMPLE:
ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE PROVIDING SERVICES NOT ELSEWHERE SPECIFIED, INCLUDING REPAIRS, RELIGIOUS ACTIVITIES,
GRANT MAKING, ADVOCACY, LAUNDRY, PERSONAL CARE, DEATH CARE, AND OTHER
PERSONAL SERVICES.
AUTOMOTIVE
ELECTRONIC
COMPUTER
COMMUNICATION
COMMERCIAL AND
INDUSTRIAL MACHINERY
REPAIRS
SUPPORT ACTIVITY, EXCAVATING SLUSH PITS, GEOLOGICAL
OBSERVATIONS, GRADING AND
BUILDING FOUNDATIONS AT
WELL LOCATIONS
BARBER
BEAUTY AND NAIL SALONS
PET CARE (GROOMING,
AND/OR BOARDING)
SPECIFY THE TYPE OF SERVICE PROVIDED. FOR EXAMPLE:
PROFESSIONAL, SCIENTIFIC, AND TECHNICAL SERVICES
ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE PERFORMING PROFESSIONAL, SCIENTIFIC, AND TECHNICAL SERVICES FOR THE OPERATIONS OF OTHER
ORGANIZATIONS.
LEGAL ADVICE AND REPRESENTATION
ACCOUNTING
BOOKKEEPING
PAYROLL SERVICES
ARCHITECTURAL
ENGINEERING
COMPUTER SERVICES
CONSULTING
RESEARCH
ADVERTISING
PHOTOGRAPHIC
TRANSLATION AND INTERPRETATION
VETERINARY SERVICES
ZONING BOARDS AND COMMISSIONS ( PUBLIC
ADMINISTRATION)
GOVERNMENT URBAN
PLANNING COMMISSIONS
CIVILIAN COURTS OF LAW
SPECIFY OFFICE. FOR EXAMPLE:
PUBLIC ADMINISTRATION
ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE ADMINISTRATION,
MANAGEMENT, AND OVERSIGHT OF PUBLIC PROGRAMS BY FEDERAL, STATE, AND
LOCAL GOVERNMENTS.
EXECUTIVE OFFICES OF
PRESIDENT
GOVERNORS AND MAYORS IN
ADDITION TO EXECUTIVE
ADVISORY COMMISSIONS
REAL ESTATE
SPECIFY THE TYPE OF REAL ESTATE ACTIVITY. FOR EXAMPLE:
ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE RENTING, LEASING,
OR OTHERWISE ALLOWING THE USE OF TANGIBLE OR INTANGIBLE ASSETS (EXCEPT
COPYRIGHTED WORKS), AND PROVIDING RELATED SERVICES.
SELF-STORAGE RENTAL, REAL
ESTATE
AGENTS/BROKERS
CAR RENTAL/LEASING
RETAIL TRADE
SPECIFY THE DIFFERENT TYPES OF RETAIL STORES. FOR EXAMPLE:
ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR RETAIL MERCHANDISE,
GENERALLY IN SMALL QUANTITIES, TO THE GENERAL PUBLIC, AND PROVIDE SERVICES
INCIDENTAL TO THE SALE OF THE MERCHANDISE.
DEPARTMENT STORES
FURNITURE STORES
SANITARY SERVICE
SPECIFY THE TYPE OF SERVICE PROVIDED. FOR EXAMPLE:
ESTABLISHMENTS ENGAGED IN ACTIVITIES IN THIS SECTOR ARE INVOLVED IN THE
COLLECTION, TREATMENT, AND DISPOSAL OF WASTE MATERIALS NOT THROUGH
SEWER SYSTEMS OR SEWAGE TREATMENT FACILITIES.
LOCAL HAULING OF WASTE
MATERIALS
REMEDIATION SERVICES
SOCIAL ASSISTANCE SERVICE
SPECIFY THE TYPE OF SERVICE PROVIDED. FOR EXAMPLE:
ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR PROVIDE A WIDE VARIETY
OF SOCIAL ASSISTANCE SERVICES DIRECTLY TO THEIR CLIENTS. THESE SERVICES DO
NOT INCLUDE RESIDENTIAL OR ACCOMMODATION SERVICES, EXCEPT ON A SHORT
STAY BASIS.
YOUTH CENTERS
TEMPORARY SHELTERS
ADOPTION AGENCIES
SERVICES FOR ELDERLY AND
PERSONS WITH DISABILITIES
TRANSPORTATION
ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR PROVIDE TRANSPORTATION OF PASSENGERS AND CARGO, SCENIC AND SIGHTSEEING TRANSPORTATION,
AND SUPPORT ACTIVITIES RELATED TO MODES OF TRANSPORTATION.
CONSUMER GOODS
COMMERCIAL AND
INDUSTRIAL
MACHINERY/EQUIPMENT
CLOTHING AND GROCERY
IN-HOME DEMONSTRATION,
INFOMERCIALS
SEPTIC PUMPING
HAZARDOUS AND
NON-HAZARDOUS WASTE
TRANSFER STATIONS
COURTS OF LAW AND
SHERIFFS OFFICES CONDUCTING COURT FUNCTIONS ONLY
PATENTS
TRADEMARKS
BRAND NAMES, AND/OR FRANCHISE AGREEMENT
VENDING MACHINES AND
STREET VENDORS
(EXCEPT FOOD)
SOLID WASTE LANDFILLS
COMBUSTORS AND
INCINERATORS
CHILD DAY CARE
SPECIFY THE TYPE OF TRANSPORTATION MODE. FOR EXAMPLE:
AIR (SPECIFY SCHEDULED OR
NONSCHEDULED; PASSENGER
OR FREIGHT)
RAIL, DEEP SEA, COASTAL,
AND GREAT LAKES
TRUCKING (GENERAL OR SPECIALIZED LONG-DISTANCE OR
LOCAL)
UTILITIES
SPECIFY THE TYPE OF SERVICE. FOR EXAMPLE:
ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR PROVIDE ELECTRIC
POWER, NATURAL GAS, STEAM SUPPLY, WATER SUPPLY, AND SEWAGE REMOVAL. THE
SPECIFIC ACTIVITIES ASSOCIATED WITH THE UTILITY SERVICES PROVIDED VARY BY
UTILITY: ELECTRIC POWER INCLUDES GENERATION, TRANSMISSION, AND DISTRIBUTION; NATURAL GAS INCLUDES DISTRIBUTION; STEAM SUPPLY INCLUDES PROVISION
AND/OR DISTRIBUTION; WATER SUPPLY INCLUDES TREATMENT AND DISTRIBUTION;
AND SEWAGE REMOVAL INCLUDES COLLECTION, TREATMENT, AND DISPOSAL OF
WASTE THROUGH SEWER SYSTEMS AND SEWAGE TREATMENT FACILITIES.
ELECTRIC
HYDROELECTRIC
NUCLEAR
FOSSIL FUEL
TRANSMISSION
WAREHOUSING
SPECIFY THE TYPE OF STORAGE. FOR EXAMPLE:
ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR ARE PRIMARILY
ENGAGED IN OPERATING WAREHOUSING AND STORAGE FACILITIES FOR GENERAL
MERCHANDISE, REFRIGERATED GOODS, AND OTHER WAREHOUSE PRODUCTS,
WHICH MAY INCLUDE LOGISTICS.
GENERAL WAREHOUSING
WHOLESALE TRADE
SPECIFY THE DIFFERENT TYPES OF TRADERS. FOR EXAMPLE:
ESTABLISHMENTS ENGAGED IN ACTIVITIES OF THIS SECTOR COMPRISE TWO MAIN
TYPES OF ENTERPRISES SELLING OR ARRANGING FOR THE PURCHASE OR SALE OF
GOODS FOR RESALE; CAPITAL OR DURABLE NON-CONSUMER GOODS; AND RAW AND
INTERMEDIATE MATERIALS AND SUPPLIES USED IN PRODUCTION, AND PROVIDING
SERVICES INCIDENTAL TO THE SALE OF THE MERCHANDISE.
MERCHANT WHOLESALERS
(DISTRIBUTORS, JOBBERS,
DROP SHIPPERS, AND
IMPORT/EXPORT MERCHANTS)
BUS
TAXI
SCHOOL BUS
LIMOUSINE
DISTRIBUTION
WATER TREATMENT AND/OR
WATER SUPPLY SYSTEMS
SEWAGE TREATMENT
FACILITIES
REFRIGERATED
FARM PRODUCTS
BUSINESS TO BUSINESS ELECTRONIC MARKETS
EXCLUDED ARE RENTING AND
LEASING SPACE FOR SELFSTORAGE – SEE REAL ESTATE
AGENTS, AND BROKERS
ARRANGING SALES AND PURCHASES FOR OTHERS ON A
FEE OR COMMISSION BASIS
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 percentage types should equal 100 percent of the construction activity at this establishment.
21
www.paopen4business.state.pa.us, or call the PA Department of Revenue at (717) 787-1064.
SECTION 8 – ESTABLISHMENT SALES INFORMATION
1.
2.
3.
Check the appropriate box to indicate if the establishment is
selling products or services subject to Sales Tax in PA. Products 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. Complete Section 18 to apply for a PA Sales Tax License.
SECTION 12 – REPORTING & PAYMENT METHODS
1.
Check the appropriate box to indicate if cigarettes are sold
over-the-counter or at vending machine locations. Complete Section 18 to apply for a Sales Tax License and Section 19 to apply for a Cigarette Tax License.
List each county in PA where taxable sales and/or services are offered or supplied.
The enterprise may participate voluntarily in the Department of Revenue’s EFT Program.
2.
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.
a – c Complete if the establishment employs PA residents
working outside of PA.
3.
Check the appropriate box. If yes, explain the services performed and why you do not consider the individual(s) to be
employee(s).
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
enterprise. Non-profit enterprises must pay for one-half of
any extended benefits, while political subdivisions must pay
the full amount of any extended benefits.
An enterprise will be assigned the contributory method of
payment unless they file an election for reimbursement coverage with the PA Department of Labor & Industry.
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.
UC Employee Withholding Contributions: Enterprises
are required to report gross wages paid to employees,
regardless of the method used to finance UC costs (contributory 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 percentage of gross wages. Employee contributions are not
credited to an enterprise‘s reserve account balance, nor
are they considered to be contributions for federal certification purposes under the Federal Unemployment Tax Act.
SECTION 10 – BULK SALE/TRANSFER INFORMATION
A separate copy of Section 10 must be completed for each transferor 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.
2.
Additional information is available by contacting the nearest
Department of Labor & Industry Field Accounting Service
Office.
Indicate if the enterprise has acquired “IN BULK” 51 percent or more of the total assets of another enterprise.
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.paopen4business.state.pa.us, or call the PA Department of State at (717) 787-1057.
1-6. Describe the corporation.
7.
Payments for UC should be made payable to the PA Unemployment Compensation Fund.
Indicate if the enterprise has acquired “IN BULK” 51 percent
or more of any class of PA assets of another enterprise.
3-7. Complete if the answer to question 1 or 2 is “Yes”.
Check the appropriate box if the corporation is a federal
“S” corporation. If so, check the box to indicate if the corporation is also a PA “S” corporation. Note: This does
not constitute a PA “S” election. To elect PA “S” status, a
REV-1640, Election and Shareholder’s Consent Form
must be submitted. To complete this form on-line visit
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 contribution may change from year to year.
For-profit enterprises must pay under the contributory method.
Check the appropriate box in g-3 if the establishment is not
required to have workers’ compensation coverage and provide bureau code.
2.
Payments equal to or greater than $20,000 to the Department 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.
3.
Enterprises with 250 or more wage entries are required to
report quarterly Unemployment Compensation wages to
the Department of Labor & Industry via magnetic media.
Non-compliance may result in penalty charges. Enterprises may also voluntarily report individuals’ wages to the
Department of Labor & Industry in the same media. Any
magnetic reporting file must be submitted for compatibility with the Department of Labor & Industry’s format. Contact the Magnetic Media Reporting Unit at (717) 783-5802
for more information.
The Commonwealth’s Electronic Tax Information and Data
Exchange System (E-TIDES) is an Internet based filing and
payment system that can be used to simplify reporting
requirements for Unemployment Compensation, 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 home page at www.etides.state.pa.us.
22
SECTION 13 – GOVERNMENT STRUCTURE
8.
Enter the percentage of the predecessor‘s total business
operation acquired. Total business operation is defined as
all activities reportable under a single Federal Employer
Identification Number (EIN) including any activities occurring outside of PA.
9.
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.
Enter the percentage of the predecessor’s PA business operation acquired. If less than 100 percent, provide the additional information as requested on the form.
3.
If the enterprise is a Domestic/USA form of government,
check the appropriate box.
10. Describe the PA business activity(ies) that the registering
enterprise acquired from the predecessor.
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 organization will be assigned the reimbursement method.
11. Check the appropriate box(es) to indicate the type(s) of
assets acquired from the predecessor.
See page 22 of the instructions for further explanations regarding contributory and reimbursement methods of making payments to the Unemployment Compensation Fund.
SECTION 14 – PREDECESSOR/SUCCESSOR INFORMATION
Complete this section if the registering enterprise is succeeding a predecessor (prior owner) in whole or in part. For assistance in completing Sections 14, 15, and 16, contact the
nearest Department of Labor & Industry Field Accounting Service Office.
Predecessor: An enterprise that transfers all or part of its organization, trade, or business to another enterprise.
Successor: An enterprise that acquires by transfer all or part of
the organization, trade, or business from another enterprise.
The registering enterprise may apply for the Unemployment
Compensation (UC) experience record and reserve account
balance of the predecessor by completing Section 15, Application
for PA UC Experience Record & Reserve Account Balance of Predecessor.
The Department of Labor & Industry may determine that a transfer of experience from a predecessor to the registering enterprise will be mandatory provided there is common ownership 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 predecessor‘s business operation was acquired.
Acquisition of an Existing Enterprise: Occurs when operations are continued by a new owner; for example, a purchase of all or part of the enterprise.
Change in Legal Structure: Occurs when the form of
organization changes; for example, when a sole proprietorship 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 existence terminates.
IRC Section 338 Election: Occurs when a stock purchase
is treated as an asset purchase under the Internal Revenue
Code Section 338.
7.
23
Enter the date the business operation was acquired.
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 information 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; 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, highways, buildings, factories, housing developments, or other construction 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 Sections 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 Predecessor must be filed prior to the end of the calendar year
immediately following the year in which the transfer occurred.
1-2. Complete only to apply for the predecessor‘s experience
record and reserve account balance. The authorized signature should be that of the owner, general partner, or officer 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 operation 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 Unemployment 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.
2.
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 Information (Section 9).
Identify the year(s) and calendar quarters in which contributions were payable to the PA UC Fund for taxable
wages applicable to the part of the predecessor‘s PA business operation that was transferred. Include any quarters
applicable to known pre-predecessors.
Refer to the instructions for Owners, Partners, Shareholders, Officers, and Responsible Party Information (Section 6).
Identify the year(s) and calendar quarters in which contributions were payable to the PA UC Fund for taxable
wages applicable to any part of the predecessor‘s PA
business operation that was retained. Include any quarters applicable to known pre-predecessors.
4.
For the three calendar year period prior to the year of
transfer (4a) or for a lesser period (4b) from the date
wages were first paid to the actual date of transfer
(acquisition), enter the total amount of taxable wages
applicable to the part of the predecessor‘s PA business
operation that was transferred.
5.
Enter the total amount of taxable wages applicable to the
predecessor‘s entire PA business operation for the period
that directly corresponds to the same period in item 4a or 4b.
6.
Enter the total amount of taxable wages applicable to the
predecessor‘s entire PA business operation for the period
from the beginning of the quarter the transfer occurred to
the actual date of transfer.
SECTION 17 – MULTIPLE ESTABLISHMENT INFORMATION
When an enterprise has more than one establishment conducting 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
2.
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”.
Enter the exact date wages were first paid in the part of
the predecessor‘s PA business operation 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.
3.
1.
6.
Establishment Name: Enter the name by which this
establishment is known to the public; for example, the
name on the front of the store.
Date of First Operations: Enter the first date this establishment conducted any activity in PA or employed PA residents. This includes start-up operations prior to opening
for business.
SECTION 6A – ADDITIONAL OWNERS, PARTNERS, SHAREHOLDERS,
OFFICERS, AND RESPONSIBLE PARTY INFORMATION
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 authorize the enterprise to do any of the functions listed below. Applications 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 services 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 or rental in the normal course of business sales taxfree.
PART 2 - TRANSIENT VENDOR CERTIFICATE
Complete Parts 1 and 2 to apply for a Transient Vendor Certificate. 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 proprietorship or a partnership may apply for a transient vendor certificate.
3.
Telephone Number: Enter the telephone number for this
establishment.
A Transient Vendor Certificate is needed if the enterprise:
Does not have a permanent Sales & Use Tax License.
4.
Street Address: Enter the physical location of this establishment. A post office box is not acceptable.
5.
School District: Enter the school district where this establishment is located. If not a PA school district enter “N/A”.
Brings into PA, by automobile, truck or other means of transportation, 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.
24
Offers or intends to offer tangible personal property for
retail sale in PA.
tion prior to the issuance of a license. This investigation will be
completed within 60 days of receipt of the completed application.
Does not maintain an established office, distribution house,
sales house, warehouse, service enterprise or residence
where business is conducted in PA.
PART 3 - CIGARETTE STAMPING AGENT
Complete Parts 1, 2, and 3 to apply for a Cigarette Stamping Agent
License.
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 celebrations 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.
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 Registration 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 $10 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.
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 Promoter 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 beginning February 1 of each year.
This application must be completed and returned to the Department of Revenue at least 30 days prior to the opening of the first
show.
A Distributor License expires on April 30 and is renewable on
a yearly basis.
A Manufacturer Registration Certificate expires on March 31 and
is renewable on a yearly basis.
SECTION 19 – CIGARETTE DEALER‘S LICENSE
PART 2 - DISTRIBUTOR
PART 1 - LICENSE TYPE
Complete this section to apply for a Distributor License only.
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 cigarette tax stamping will occur.
PART 3 - SMALL GAMES OF CHANCE CERTIFICATION
A Cigarette Dealer‘s License is not transferable.
If the enterprise is applying for a Cigarette Vending Machine
License, a list of machine locations 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 locations (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-
25
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.
The applicant’s authorized signature in Section 4 of the form
indicates applicant agrees to comply with the reporting, payment, 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 of 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 passengers or property by motor vehicle using the public utility commission 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 primarily 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. Government, the Commonwealth of PA and its political subdivisions,
other states publicly-owned vehicles, volunteer fire, rescue and
ambulance associations, farm vehicles, implements of husbandry, 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.
IFTA Decals: Request IFTA Decals 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.
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.
A surety bond is required for Liquid Fuels and Fuel Tax. The enterprise will be contacted by the PA Department 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 Charity Act, changes the procedure and filing requirements for organizations 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 completing the REV-72, the following documents are required and must
be attached to the application:
Carriers purchasing IFTA credentials must file Quarterly IFTA
Fuel Tax reports.
Non-IFTA Decals: For PA-qualified vehicles that travel exclusively 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 operational records; however, quarterly Motor Carrier Road Tax
reports are not required.
If a carrier is based in a non-IFTA jurisdiction and intends to operate 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 a decal is purchased, quarterly
tax reports will be required.
A copy of the Articles of Incorporation, By-laws, Constitution, or other governing legal document specifically
including:
* Aims and purpose of the institution;
A provision 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
Unemployment Compensation (UC) 717-787-7679
UC Benefit Charges
717-787-4677
Workers’ Compensation (WC)
WC Employer Help Line
717-772-3702
1-888-PATAXES
(728-2937)
PROGRAM QUESTIONS
717-783-5421
E-mail:
E-mail:
WC Self-Insurance Division 717-783-4476
[email protected]
[email protected]
WC Compliance Section
717-787-3567
Forms and information for both Departments are available at: http://www.paopen4business.state.pa.us
26
The location of these offices may change.
To verify the location of an office, please call Monday through Friday 8:30 AM to 5:00 PM (EST) at the number listed for that office.
REVENUE DISTRICT OFFICES
LOCATIONS AND COUNTIES SERVED
Altoona
(Blair, Centre, Fulton,
Huntingdon,and Mifflin)
Cricket Field Plz.
Ste. 204
615 Howard Ave.
Altoona, PA 16601-4867
(814) 946-7310
Greensburg
(Westmoreland)
Second Fl.
15 W. Third St.
Greensburg, PA 15601-3003
(724) 832-5386
New Castle
(Beaver, Butler, Lawrence,
Mercer, and Venango)
Rm. 201
101 S. Mercer St.
New Castle, PA 16101-3837
(724) 656-3203
Harrisburg
(Cumberland, Dauphin, and Perry)
Lobby
Strawberry Sq.
Harrisburg, PA 17128-0101
(717) 783-1405
Bethlehem
(Lehigh and Northampton)
44 E. Broad St.
Bethlehem, PA 18018-5998
(610) 861-2000
Newtown Square
(Chester and Delaware)
Ste. 1
90 S. Newtown St. Rd.
(Route 252)
Newtown Square, PA 19073-4090
(610) 353-4051
Indiana
(Armstrong, Clarion, Indiana,
and Jefferson)
Canterbury Office Stes.
2263 Philadelphia St.
Indiana, PA 15701-1595
(724) 357-7600
Bradford
(Cameron, Elk, Forest,
McKean, Potter, and Warren)
Second Floor
86 Boylston St.
Bradford, PA 16701-2011
(814) 368-7113
Norristown
(Montgomery)
Second Fl.
Stoney Creek Office Center
151 W. Marshall St.
Norristown, PA 19401-4739
(610) 270-1780
Johnstown
(Bedford, Cambria, Clearfield, and
Somerset)
Third Fl.
345 Main St.
Johnstown, PA 15901-1614
(814) 533-2495
Doylestown
(Bucks)
Ste. 104
600 Louis Dr.
Warminster, PA 18974-2847
(215) 443-2990
Philadelphia
(Philadelphia)
Rm. 201
State Office Bldg.
1400 W. Spring Garden St.
Philadelphia, PA 19130-4088
(215) 560-2056
Lancaster
(Lancaster and Lebanon)
Ste. 201
315 W. James St.
Lancaster, PA 17603-2911
(717) 299-7581
Erie
(Erie and Crawford)
448 W. 11th St.
Erie, PA 16501-1501
(814) 871-4491
Washington
(Fayette, Greene, and
Washington)
Rm. 204
Landmark Bldg.
75 E. Maiden St.
Washington, PA 15301-4963
(724) 223-4550
Pittsburgh
(Allegheny)
Ste. 104
State Office Bldg.
300 Liberty Ave.
Pittsburgh, PA 15222-1210
(412) 565-7540
Pottsville
(Carbon and Schuylkill)
115 S. Centre St.
Pottsville, PA 17901-3047
(570) 621-3175
Reading
(Berks)
Rm. 239
625 Cherry St.
Reading, PA 19602-1186
(610) 378-4401
Wilkes-Barre
(Luzerne and Wyoming)
Ste. 201
Thomas C. Thomas Bldg.
100 E. Union St.
Wilkes-Barre, PA 18701-3200
(570) 826-2466
Scranton
(Lackawanna, Monroe, Pike,
Susquehanna, and Wayne)
Rm. 305
Samters Bldg.
101 Penn Ave.
Scranton, PA 18503-1970
(570) 963-4585
Williamsport
(Bradford, Clinton, Lycoming,
Sullivan, and Tioga)
440 Little League Blvd.
Williamsport, PA 17701-5055
(570) 327-3475
Sunbury
(Columbia, Juniata, Montour,
Northumberland, Snyder, and Union)
535 Chestnut St.
Sunbury, PA 17801-3404
(570) 988-2834
York
(Adams, Franklin, and York)
140 N. Duke St.
York, PA 17401-1110
(717) 845-6661
LABOR & INDUSTRY FIELD ACCOUNTING SERVICE OFFICES
LOCATIONS AND COUNTIES SERVED
Allentown
1 S. Second St., Ste. 400
Allentown, PA 18102-4901
(610) 821-6559
Lehigh
Northampton
Altoona
3303 Pleasant Valley Blvd.
Altoona, PA 16601-4311
(814) 946-6991
Bedford
Blair
Centre
Huntingdon
Beaver Falls
2103 Ninth Ave.
Beaver Falls, PA 15010-3957
(724) 846-8803
Beaver
Lawrence
Bristol
1242 New Rodgers Rd.
Bristol, PA 19007-2591
(215) 781-3217
Carlisle
1 Alexandra Ct.
Carlisle, PA 17013-7667
(717) 249-8211
Chambersburg
600 Norland Ave., Ste. 7
Chambersburg, PA 17201
(717) 264-7192
Chester
2nd Fl., Ste. D
701 Crosby St.
Chester, PA 19013-6089
(610) 447-3290
Clearfield
501 E Market St., Ste. 6
Clearfield, PA 16830
(814) 765-0572
27
Bucks
Cumberland
Franklin
Fulton
Delaware
Cameron
Clearfield
Elk
Forest
Jefferson
McKean
Warren
Erie
1309 French St.
Erie, PA 16501-1999
(814) 871-4381
Greensburg
593 Sells Ln.
Greensburg, PA 15601-4458
(724) 832-5275
Crawford
Erie
Westmoreland
Harrisburg
1171 S. Cameron St., Rm. 311 Dauphin
Harrisburg, PA 17104-2591
Juniata
(717) 787-1700
Lebanon
Mifflin
Perry
Johnstown
200 Lincoln St.
Johnstown, PA 15901-1592
(814) 533-2371
Armstrong
Cambria
Indiana
Somerset
Lancaster
1016 N. Charlotte St., Ste. 109 Lancaster
P.O. Box 1563
Lancaster, PA 17608-1563
(717) 299-7606
Malvern
Century Plz., 2nd Fl.
72 Lancaster Ave.
Malvern, PA 19355-2160
(610) 647-3799
Mercer
114 W. South St.
Mercer, PA 16137-1549
(724) 662-4007
Nanticoke
40 E. Main St.
Nanticoke, PA 18634
(570) 740-2440
Norristown East/West
1885 New Hope St., 2nd Fl.
Norristown, PA 19401-3146
(610) 270-1316 - East
(610) 270-3450 - West
Philadelphia
444 N. Third St., Ste. 3B
Philadelphia, PA 19123-4190
(215) 560-3136/1828
Pittsburgh
933 Penn Ave., 2nd Fl.
Pittsburgh, PA 15222-3815
(412) 565-2400
Reading
625 Cherry St., Rm. 250
Reading, PA 19602-1184
(610) 378-4395
Scranton
135 Franklin Ave.
Scranton, PA 18503-1935
(570) 936-4686
Chester
Butler
Clarion
Mercer
Venango
Shamokin
2 E. Arch St.
P.O. Box 279
Shamokin, PA 17872-0279
(570) 644-3415
Carbon
Luzerne
Sullivan
Tannersville
Rt. 611 Merchants Plz.
P.O. Box 789
Tannersville, PA 18372-0789
(717) 620-2870
Monroe
Pike
Montgomery
Uniontown
140 N. Beeson Ave., Ste. 403 Fayette
Uniontown, PA 15401
Greene
(724) 439-7230
Philadelphia
Washington
Millcraft Center, Ste. 120UL
90 W. Chestnut St.
Washington, PA 15301
(724) 223-4530
Washington
Allegheny
Berks
Bradford
Lackawanna
Susquehanna
Wayne
Wyoming
Columbia
Montour
Northumberland
Schuylkill
Snyder
Union
Williamsport
208 W. Third St., Ste. 301
Williamsport, PA 17701-6477
(570) 327-3525
York
841 Vogelsong Rd.
P.O. Box 14008
York, PA 17404-0868
(717) 767-7620
Out-of-State
L & I Bldg., Rm. 703
Seventh & Forster Sts.
Harrisburg, PA 17121-0001
(717) 787-5939
Clinton
Lycoming
Potter
Tioga
Adams
York
Those
enterprises
not having a
PA location.
For the hearing impaired only
(717) 783-3545