Form 83-T-5 - Application For Philadelphia Business Tax Account Number, Commercial Activity License, Wage Tax Withholding Account

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CITY OF PHILADELPHIA
DEPARTMENT USE ONLY
APPLICATION FOR
PHILADELPHIA BUSINESS TAX ACCOUNT NUMBER
PHILADELPHIA BUSINESS TAX ACCOUNT NUMBER
COMMERCIAL ACTIVITY LICENSE
-
WAGE TAX WITHHOLDING ACCOUNT
PHILADELPHIA COMMERCIAL ACTIVITY LICENSE NUMBER
READ INSTRUCTIONS ON REVERSE BEFORE COMPLETING THIS FORM
CLEARLY PRINT OR TYPE ALL INFORMATION
You can register online at https://
REVENUE CODE 3702
There is no fee for a Commercial Activity License.
YOU MUST ENTER YOUR FEDERAL EMPLOYER
1A. IF THIS ACCOUNT IS FOR WAGE TAX WITHHOLDING ONLY, CHECK HERE:
IDENTIFICATION AND/OR SOCIAL SECURITY NUMBER
1B. IF THIS ACCOUNT IS FOR NET PROFITS TAX ONLY, CHECK HERE:
EMPLOYER IDENTIFICATION NUMBER
2A. DATE PHILADELPHIA BUSINESS BEGAN
2B. ARE YOU CLAIMING "NEW BUSINESS" TAX STATUS
-
UNDER PHILADELPHIA CODE 19-3800?
-
-
SOCIAL SECURITY NUMBER
YES
NO
-
-
YES
NO
3. DO YOU NEED PRIOR YEAR TAX FORMS?
PA STATE SALES and USE TAX NUMBER
-
-
4. DATE WAGES FIRST PAID
-
$
,
,
. 0 0
5. TAXABLE MONTHLY PAYROLL
6A. PRIMARY TYPE OF BUSINESS
CONSTRUCTION
WHOLESALE
RETAIL
MANUFACTURING
SERVICES
OTHER
6B. DESCRIBE EXACT TYPE OF BUSINESS
7. ENTITY NAME
8. TRADE NAME (IF APPLICABLE)
9. BUSINESS ADDRESS (NUMBER AND STREET. DO NOT USE P.O BOX NUMBERS.)
CITY
STATE ZIP CODE
OWN
RENT
10. MAILING ADDRESS (IF DIFFERENT FROM BUSINESS ADDRESS.)
CITY
STATE ZIP CODE
11. BRANCH OFFICE ADDRESS, IF ANY. (IF MULTIPLE LOCATIONS, ATTACH SEPARATE SHEET.)
CITY
STATE ZIP CODE
OWN
RENT
12. BUSINESS TELEPHONE NUMBER
13. HOME TELEPHONE NUMBER
14. FAX NUMBER
15. E-MAIL ADDRESS
16. TYPE OF ORGANIZATION (CHECK ONE)
PARTNERSHIP
JOINT VENTURE
LIMITED LIABILITY COMPANY (LLC)
D)
E)
F)
SOLE PROPRIETOR
A)
DISREGARDED ENTITY (LLC)
GENERAL PARTNERSHIP
LIMITED LIABILITY PARTNERSHIP
CORPORATION
PARTNERSHIP
Check here if
CORPORATION
B)
any member
LIMITED PARTNERSHIP
SOLE PROPRIETORSHIP
is a corporation.
Check here if any
If Disregarded Entity, enter the City account
ESTATE/TRUST
C)
member is a corporation.
number of the parent company_______________
NON-PROFIT UNDER INTERNAL REVENUE CODE §501 (C) (3)
WAGE TAX ONLY
G)
GOVERNMENT
H)
ASSOCIATION
I)
(ATTACH COPY OF THE IRS EXEMPTION LETTER.)
17. INDIVIDUALS, PARTNERS OR OFFICERS NAMES
18. HOME ADDRESS
19. SSN OR FEDERAL EIN
20A. VOLUNTARY DISCLOSURE OF RACE AND GENDER INFORMATION
20B. PRIMARY LANGUAGE OF BUSINESS OWNER
RACE/NATIONAL ORIGIN:
ENGLISH
SPANISH
KOREAN
ASIAN, PACIFIC ISLANDER
BLACK
HISPANIC
WHITE
OTHER (SPECIFY):
RUSSIAN
OTHER (SPECIFY):
MALE
FEMALE
SEX:
I understand that if I knowingly make any false statement(s) herein, I am subject to penalties as prescribed by law.
SIGNATURE
PRINT NAME
PHONE NUMBER
DATE
Mail the completed application to the CITY OF PHILADELPHIA, DEPARTMENT OF REVENUE, P.O. BOX 1600,
PHILADELPHIA, PA 19105-1600 or FAX to 215-686-6635. If submitting by fax, do not mail this form.
83-T-5 Rev. 01-13-2014

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