Electronic Data Interchange (Edi) Trading Partner Agreement Form - Pennsylvania Department Of Revenue Page 2
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1
2FEDERAL ID# (EIN/SSN)
Check the appropriate block(s) to indicate the tax(es) that will be filed by EDI. Enter the account number for each tax type checked. Sign and
date the agreement.
Account No.
Sales and Use Tax
.
Authorized Signature:
Print Name
Last
First
Middle I.
Title
Date
Signature of Above Individual
Telephone Number
(
)
Account No.
Employer Withholding Tax
.
Authorized Signature:
Print Name
Last
First
Middle I.
Title
Date
Signature of Above Individual
Telephone Number
(
)
Account No.
Motor Fuels Tax
.
Authorized Signature:
Print Name
Last
First
Middle I.
Title
Date
Signature of Above Individual
Telephone Number
(
)
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be duly executed as
of the day and year listed below.
STATE OF
:
:ss
COUNTY OF
:
On this
day of
,
, before me, a Notary Public in and for the county and state aforesaid, personally appeared
the individual identified above who acknowledged that he executed the foregoing instrument.
Sworn to and subscribed before me
this
day of
,
.
Notary Public
My Commission Expires:
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