Form 83-T-5 - Application For Philadelphia Business Tax Account Number Business Privilege License Wage Tax Withholding Account
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1
2CITY OF PHILADELPHIA
DEPARTMENT USE ONLY
APPLICATION FOR
PHILADELPHIA BUSINESS TAX ACCOUNT NUMBER
PHILADELPHIA BUSINESS TAX ACCOUNT NUMBER
BUSINESS PRIVILEGE LICENSE
-
WAGE TAX WITHHOLDING ACCOUNT
PHILA DELPHIA BUSINESS PRIVILE GE LICENSE NUMBER
READ INSTRUCTIONS ON REVERSE BEFORE COMPLETING THIS FORM
CLEARLY PRINT OR TYPE ALL INFORMATION
1A. IF THIS ACCOUNT IS FOR WAG E TAX WITHHOLDING ONLY, CHECK HERE
FEDERAL EMPLOY ER IDENTIFICATIO N NUMBER
1B. IF THIS ACCOUNT IS FOR NET PROFITS TAX ONLY, CHECK HERE
-
2. DATE PHIL ADELP HIA BUSINESS BEGAN
3. DO YOU NEED PRIOR YEAR(S) TAX FO RMS?
-
-
YES
NO
SOCIAL SECURITY NUMBER
4. DATE WAG ES FI RST PAID
5. TAXAB LE MONTHLY PAYROLL
-
-
-
-
6. PRIMARY TYPE OF BUSINESS
YOU MUST ENTER YOUR FEDERAL EMPLOYER
IDENTIFICATION AND/OR SOCIAL SECURITY NUMBER
RETAIL
CONSTRUCTION
WHOLESA LE
MANUFACTURING
SERVICES
OTHER
6A. DESCRIBE EXACT TY PE O F BUSINESS
7. PA. STATE SALES TAX NUMBER
-
8. ENTITY NAME
8A. TRADE NAME (IF A PPLICABLE)
9. MAILING ADDRESS
CITY
STATE
ZIP CODE
CITY
STATE
ZIP CODE
10. BUSI NESS ADDRESS (NUMBER AND STREET. DO NOT USE P .O. BOX NUMBERS.)
OW N RENT
11. BRANCH OFFICE A DDRESS (IF ANY) IF MORE THAN ONE LOCATI ON, ATTA CH A SEP ARATE SHEET.
CITY
STATE
ZIP CODE
OWN
RENT
12. BUSI NESS TE LEPHONE NUMBER
13. HOME TELEPHONE NUMBER
14. FAX NUMBER
15. E-MAIL ADDRESS
16. TYPE OF O RGANIZATIO N (CHECK ONE)
D)
LIMITED LIABILITY COMPANY (LLC)
E)
PARTNERSHIP
F)
JOINT VENTURE
A)
SOLE PROPRIETOR
FILING BASIS WITH THE I NTERNAL REVE NUE SERVICE:
GENERAL PARTNERSHIP
(darken one circle)
Check h ere if a ny member
LIMITED P ARTNERSHIP
CORPORATION
B)
CORPORATION
is a corporation.
LIMITED LIABILITY PA RTNERSHIP
SOLE PROPRIETOR
C)
ESTATE/TRUST
Check here if any member
PARTNERSHIP
is a corporation.
NON-PROFIT UNDER INTERNAL REVENUE CODE §501(C) (3).
WAGE TAX O NLY
GOVERNME NT
ASSOCIATION
G)
H)
I)
ATTACH A COPY OF THE IRS EXEMPTION LETTER.
17. INDIVI DUALS, PARTNERS OR O FFICERS NAMES
18. HOME ADDRESS
19. SO CIAL SECURITY NUMBER OR FEDERAL EIN
20. VO LUNTARY DISCLO SURE OF RACE AND GENDER INFORMATION
CITY OF PHILADELPHIA USE ONLY
REVENUE CODE 3702
RACE/NATIONAL ORI GIN:
ASIAN, PACIFIC ISLANDER
MAIL COMPLETED APPLICATION TO:
BLACK
HISPANIC
WHITE
CITY OF PHILADELPHIA
DEPARTMENT OF REVENUE
P.O. BOX 1600
OTHER
PHILADELPHIA, PA 19105-1600
(specify)__________ _______________________ ___________________
OR FAX TO: 215-686-6635
MALE
FEMALE
SEX:
(If submitting by fax, do not mail.)
I understand that if I knowingly make any false sta tement(s) herein, I am subject to penalties a s prescribed by law.
____________________________
______________________
_____________
_________
SIGNATURE
PRINT NAME
PHONE NUMBER
DA TE
83-T-5 Rev. 1-5-2005
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