Form 83-T-104a - Employee Earnings Tax Account Application - City Of Philadelphia - Department Of Revenue

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CITY OF PHILADELPHIA
2007 APPLICATION FOR
DEPARTMENT OF REVENUE
EMPLOYEE EARNINGS (WAGE) TAX ACCOUNT
Your Social Se curity Number is your Em ployee Earnings Tax Account Number.
Do not file this application if Philadelphia wage tax was withheld on all compensation.
APPLICANT'S NAME (PRINT)
SOCIAL SE CURITY NUMBER
-
-
HOME ADDRESS
CITY
STATE
ZIP CODE
DAYTIME TELEPHONE NUMBER
FAX NUMBER
E-MAIL A DDRESS
EMPLOY ER'S NAME
EMPLOY ER'S FEDERAL TAX I DENTIFICATION NUMBER
-
EMPLOY ER'S ADDRESS
CITY
STATE
ZIP CODE
EMPLOYER'S TELE PHONE NUMBER
FAX NUMBER
E-MAIL A DDRESS
ARE YO U STILL E MPLOYED
EMPLOY MENT START DATE
IF NO, ENTER SEP ARATION DATE:
BY THIS EMPLO YER?
-
-
-
-
YES
NO
I HEREBY CERTIFY that the statements contained herein and in any supporting schedule or exhibit are true and correct to the best of my
knowledge and belief. I understand that if I knowingly make any false statements herein, I am subject to penalties as prescribed by law.
APPLICANT'S SIG NATURE
DATE
M AIL COM PLETED APPLICATION TO:
CITY OF PHILADELPHIA
DEPARTMENT OF REVENUE
1401 JOHN F. KENNEDY BOULEV ARD
PHILADELPHI A, PA 19102
OR FAX TO: 215-686-6635
Complete this portion if remittance is accompanying application. Make check payable to: "City of Philadelphia"
--------------------------------------------------------------------------------------------------------------------------------------------
EMPLOYEE QUARTERLY EARNINGS (WAGE) TAX PAYMENT COUPON
SOCIAL SECURITY NUMBER
Print name:
-
-
Enter Tax Quarter
Address:
1.
3.
JANUARY - MARCH
JULY - S EPTEMBER
2.
4.
APRIL - JUNE
OCTOBER - DECEMBER
,
,
. 0 0
1. Taxable Compensation........................... .............................. ............... ............... .........
,
. 0 0
2. RESIDENTS tax due (Line 1 times .0426).................... ............... ............... ............... ..
,
. 0 0
3. NON-RESIDENTS tax due (Line 1 times .037557)................... ............... ............... .....
,
. 0 0
4. Interest and Penalty (See reverse)................. .............................. ............... ...............
,
. 0 0
5. TOTAL DUE (Add Lines 2, 3 and 4) ........................ ............... ............... ......................
83-T-104A (Rev. 1-3-2007)

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