Form Rev-563 - Responsible Party Information Form

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REV-563 AS (4-11)

RESPONSIBLE PARTY INFORMATION FORM

SECTION I.

Start

PLEASE INDICATE ALL TAXES YOUR BUSINESS IS REGISTERED FOR:

LEGAL NAME

EMPLOYER WITHHOLDING

LIQUID FUEL

ACCOUNT ID

SALES TAX

CORPORATION TAX

BOX #: ___________

ENTITY ID

PTA/VRT

SECTION II.

INDIVIDUAL OWNER(S), PARTNER(S) OR CORPORATE OFFICER(S) RESPONSIBLE FOR TAX RETURN INFORMATION. OWNERSHIP CHANGE REQUIRES A NEW PA-100 REGISTRATION FORM.

RESPONSIBLE PARTY NAME

SSN

HOME ADDRESS

TITLE

DAYTIME TELEPHONE

EXT.

EFFECTIVE DATE

END DATE

SIGNATURE

RESPONSIBLE PARTY NAME

SSN

HOME ADDRESS