Pennsylvania Application for a PA Tax Clearance Certificate

Application for a PA Tax Clearance Certificate
Application for Tax Clearance Certificate (REV-181)
REV-181 (CM) 02-21

Department Use Only

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Bureau of Compliance
PO BOX 280947
Harrisburg PA 17128-0947

APPLICATION FOR TAX
CLEARANCE CERTIFICATE

1

name of Business

2

Location of Business (Current Mailing Address)

3

Revenue id

Please Type or Print

NO FILING FEE

Federal ein

P.O. Box, Street and number or R.d. number and Box number

Telephone number

City or Town

(
State

County

)
ZiP Code

name, Address and Phone number of Attorney or Representative to whom Clearance Certificate should be sent (if different from #2)
name

Telephone number
(
)

P.O. Box, Street and number or R.d. number and Box number
City or Town
4

5

County

State

ZiP Code

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

City

State

ZiP Code

name

Social Security number

Telephone number

P.O. Box, Street and number or R.d. number and Box number

City

(
State

)
ZiP Code

Type of Business
dOMeSTiC CORPORATiOn (incorporated in PA)

FOReiGn CORPORATiOn (not incorporated in PA)

PARTneRSHiP

PROPRieTORSHiP

(Please submit copy of 501(c)
exemption letter)

ASSOCiATiOn

BuSineSS TRuST

LiquidATinG TRuST

LiMiTed LiABiLiTy PARTneRSHiP

OTHeR (Specify)

LiMiTed LiABiLiTy COMPAny

if domestic Corporation, give incorporation date.
MM/DD/YYYY

nOnPROFiT CORPORATiOn

if Foreign Corporation, give state where incorporated and date of Certificate of Authority in PA.
MM/DD/YYYY

Registered Pennsylvania Address, P.O. Box, Street and number
City or Town

County

State

ZiP Code

6

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

7

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

8

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

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Page 2

9

Were the assets or activities of the business acquired in whole or in part from a prior business entity?
Yes
No ( If “Yes”, give predecessor’s name, address and acquisition date. )
Name

Acquisition Date
MM/DD/YYYY

P.O. Box, Street and Number
City or Town
10

County

State

ZIP Code

Has the business held title to any real estate in the last five years from the date of this application?

Yes

No

l If “Yes”, complete Schedule A (last page).
l If you currently hold title to real estate in PA, complete Schedule B (last page).
11

12

If “Yes”, complete:

Will the assets or activities of the business be transferred to another?
A.

Corporation

Yes

No

F. Other

B.

Partnership

Yes

No

Explain:

C.

Proprietorship

Yes

No

D.

Liquidating Trust

Yes

No

E.

Association

Yes

No

Yes

Name of New Owner

No

Street Address of New Owner
City

State

ZIP Code

Purpose of Clearance Certificate (check appropriate block):
A. Dissolution of Corporation or Association through Department of State.
B. Dissolution of Corporation or Association through Court of Common Pleas. Date Court was petitioned and county:
(date) MM/DD/YYYY

(county)

C. Withdrawal of Foreign Corporation through Department of State
D. Merger or consolidation of two or more Corporations or Associations where surviving Corporation or Association is not subject to the
jurisdiction of Pennsylvania. (See 15 Pa C.S. § 139.)
MM/DD/YYYY

E. Bulk Sale Clearance Certificate under Section 1403 of the Fiscal Code. Sale date:
Copy of settlement statement:
Corporation Tax Purposes

Employer Withholding Tax Purposes

Sales, Use and Hotel Occupancy Tax Purposes

Unemployment Compensation Tax Purposes

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

Title

Date

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

13

Location of business records, available for audit of Pennsylvania operations.
P.O. Box, Street and Number

City

State

ZIP Code

Telephone Number
14

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

15

Did the business ever, within the Commonwealth of PA:
(a) Engage in the sale of soft drinks or soft drink syrup ........................................................

No

Period

MM/DD/YYYY
to

(b) Own or lease and operate diesel-powered motor vehicles on PA highways?....................

Yes

No

Period

to

(c)

Yes

No

Period

to

Engage in the sale of diesel fuel to motor vehicles using PA highways? ..........................

(d) Engage in the sale or lease of tangible personal property since Sept. 1, 1953? ..............

Yes

No

Period

to

(e) File PA Unemployment Compensation Reports?................................................................

Yes

No

Period

to

If “Yes”, give Account Number
16

Yes

(See question 8k.)

Have you terminated your business activities in Pennsylvania?
Yes

No

l If “Yes”, give distribution of assets date:

MM/DD/YYYY

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

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Yes

No

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17

number of employees and total gross payrolls during the last five operating years (as reported to the Social Security Administration):
yeAR

TOTAL eMPLOyeeS

PA
eMPLOyeeS

TOTAL GROSS
PAyROLL

PA
GROSS PAyROLL

18

Have the officers received any remuneration, in cash or other other form, for services performed in Pennsylvania during the current calendar
year or during any of the preceding four calendar years?

19

Were any remunerated services performed for the business in PA, which you believe did not constitute “employment” as defined
in the PA unemployment Compensation Law?
yes
no
if “yes”, explain:

20

A.

Average number of stockholders during the last five years:

B.

number of stockholders as of this report:

C.

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

yes

no

name:

d.
21

Address:

Were all shares presented and property redeemed from any stock called for redemption or retired?

no

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

Total Assets:
22

yes

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

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

23

Have you consumed or used in Pennsylvania any tangible personal property or acquired such, after March 6, 1956, on which no PA sales or use
tax was paid? if “yes”, please explain:
yes
no

24

do you have within your custody, possession or control any abandoned and unclaimed (escheatable) funds or assets such as dividends,
payroll, deposits, outstanding checks, stock certificates, unidentified deposits, accounts payable debit balances, gift certificates, outstanding
debentures or interest, royalties, mineral rights or funds due missing shareholders or other unclaimed amounts payable?
yes
no

25

Has the business filed a PA Abandoned and unclaimed Property Report for the preceding year?
yes
no

26

CeRTiFiCATiOn: i certify that the information provided (including Schedules, if applicable) on this application has been examined by me and
is, to the best of my knowledge, true and correct. (Certification must agree with individuals listed in question 4.)
Print name

Original Signature

Signature of Officer – Please sign after printing

Print name

Original Signature

Signature of Officer – Please sign after printing

This form will serve as an application for clearances from both the PA department of Revenue and PA department of Labor & industry.

nOTe:

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

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SCHEDULE A - STATEMENT OF ACQUISITION AND/OR DISPOSITION OF PENNSYLVANIA REAL ESTATE WITHIN FIVE YEARS FROM THE DATE OF THIS APPLICATION
Name of Transferee (EE)
or Transferor (OR).
Indicate each by symbol
EE or OR.

Date of
Transfer

MM/DD/YYYY

Property Location by
Local Political Subdivision
& County

Property Location by
Local Political Subdivision
& County

Original Cost
Acquisition
Date

Land

Building

County
Assessed Value

Actual Monetary Worth
(Market Value)
at Time of Transfer

Amount of PA Realty
Stamps Affixed to
Document

Explanation

Actual Consideration including
Encumbrance
Assumed

Actual Monetary Worth
(Market Value)
at Time of Transfer

Amount of PA Realty
Stamps Affixed to
Document

Explanation

*

MM/DD/YYYY

Acquisition
Date
MM/DD/YYYY

Actual Consideration including
Encumbrance
Assumed

Original Cost
Land

Building

County
Assessed Value

*

*

*

**

**

SCHEDULE B
STATEMENT
OF ALL
PENNSYLVANIA
REAL ESTATE
NOW OWNED

*
**

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

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