PA-100 (03-09)
MAIL COMPLETED APPLICATION TO:
DEPARTMENT OF REVENUE
BUREAU OF BUSINESS TRUST FUND TAXES
PO BOX 280901
HARRISBURG, PA 17128-0901
TYPE OR PRINT LEGIBLY, USE BLACK INK
COMMONWEALTH OF PENNSYLVANIA
PA ENTERPRISE
REGISTRATION FORM
DEPARTMENT USE ONLY
RECEIVED DATE
DEPRTMENT OF REVENUE & DEPRTMENT OF LR D INDUSTRY
SECTION 1 – REASON FOR THIS REGISTRATION
REFER TO THE INSTRUCTIONS E D CHECK THE ICE BOXTO INDI |
CTE THE RENFOR THIS REGISTRTION. |
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NEW REGISTRTION |
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DING T& SERVICE |
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RETIVTING T& SERVICE |
4. DING ESTISHMENT
5. INFORMTION UPDTE
6. DID THIS ENTERPRISE: |
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YES |
NO |
QUIRE L OR PRT OF OTHER BUSINESS? |
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NO |
RESULT FROM CHGE IN LEG STRUCTURE OR EXE FROM INDIVIDU |
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PROPRIETOR TO CORPORTION PRTNERSHIP TO CORPORTION COR |
PORTION |
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TO LIMITED LILITY COMPYETC |
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NO |
UNDERGO MERGER CONSOLIDTION DISSOLUTION OR OTHER REST |
RUCTURING? |
SECTION 2 – ENTERPRISE INFORMATION |
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DTE OF FIRST OPERTIONS |
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. DTE OF FIRST OPERTIONS IN P |
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ENTERPRISE FISC YE END |
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4. |
ENTERPRISE LEG N |
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5. FEDER EMPLOYER IDENTIFICTION NUMBER N |
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6. ENTERPRISE TRE Nf different than legal name |
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. ENTERPRISE TELEPHONE NUMBER |
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ENTERPRISE STREETDRESS |
do ot use PO Box |
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CITY/TOWN |
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COUNTY |
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STTE |
ZIP CODE + 4 |
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. ENTERPRISE MLING DRESS f different than street address |
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CITY/TO |
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STTE |
ZIP CODE + 4 |
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. LOCTION OF ENTERPRISE RECORDS reet address |
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CITY/TOWN |
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STTE |
ZIP CODE + 4 |
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. ESTISHMENT Noing business as |
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PSCHOOL DISTRICT |
4. P |
MUNICIPLITY |
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ESTISHMENTS * |
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*ENTERPRISES WITH ONE OR MORE ESTABLISHMENTS WITHIN PA, WHOSE PA ADDRESS WAS NOT ENTERED ABOVE, MUST COMPLETE SECTION 17 (SEE GENERAL INSTRUCTIONS AND SECTION 17 FOR MORE INFORMATION)
SECTION 3 – TAXES AND SERVICES
LL REGISTRTS MUST CHECK THE ICE BOXTO INDICTE THE TD SERVIC |
EREQUESTED FOR THIS REGISTRTION D CO |
MPLETE THE |
CORRESPONDING SECTIONS INDICTED ON PES D . IF RETIVT |
ING Y PREVIOUS COUNT LIST THE COUNT NUMBERIN THE SPE PROVID |
ED. |
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PREVIOUS |
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ACCOUNT NUMBER |
CIGETTE DEERʼS LICENSE |
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CORPORTION T |
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EMPLOYER WITHHOLDING TX |
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FUELS TPERMIT |
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LIQUID FUELS TPERMIT |
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MOTOR CRIERS RO TIFT |
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PROMOTER LICENSE |
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PUBLIC TRSPORTTION |
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STCE TLICENSE |
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SES TEXEMPT STTUS |
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SECTION 4 – AUTHORIZED SIGNATURE
PREVIOUS
ACCOUNT NUMBER
SES USE HOTEL OCCUPCY
TLICENSE
SML GOF CHCE LIC./CERT.
TRSIENT VENDOR CERTIFICTE
UNEMPLOYMENT COMPENSTION
USE TX
VEHICLE RENTTX
WHOLESER CERTIFICTE
WORKERSʼ COMPENSTION COVERE
I ETHE UNDERSIGNED DECLE UNDER THE PENTIES OF PERJURY THT TH |
E STTEMENTS CONTNED HEREIN E TRUE CORRECTD COM |
PLETE. |
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THORIZED SIGNTURETTH POWER OFTTORNEY IF ICE |
DYTIME |
TELEPHONE NUMBER |
TITLE |
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PA-100 (03-09) |
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DEPRTMENT USE ONLY |
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ENTERPRISE N |
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SECTION 5 – BUSINESS STRUCTURE
CHECK THE OPRITE BOX FOR QUESTIONS & . IN DITION TO SEC |
TIONS THROUGH COMPLETE THE SECTIONINDICTED. |
. SOLE PROPRIETORSHIP NDIVIDU |
GENER PRTNERSHIP |
CITION |
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CORPORTION c. |
LIMITED PRTNERSHIP |
BUSINESS TRUST |
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GOVERNMENT c. |
LIMITED LILITY PRTNERSHIP |
ESTTE |
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JOINT VENTURE PRTNERSHIP |
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LIMITED LILITY COMPY
STTE WHERE CHTERED
RESTRICTED PROFESSION COMPY
STTE WHERE CHTERED
NONOFIT |
IS THE ENTERPRISE ORGIZED FOR PROFIT OR NONOFIT? |
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IS THE ENTERPRISE EXEMPT FROM TTION UNDER INTERN REVENUE CODE RCSEC |
TION 5 IF YES |
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PROVIDE COPY OF THE ENTERPRISE'S EXEMPTION THORIZTION LETTER FROM T |
HE INTERN REVENUE SERVICE. |
SECTION 6 – OWNERS, PARTNERS, SHAREHOLDERS, OFFICERS, AND RESPONSIBLE PARTY INFORMATION
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PROVIDE THE FOLLOWING FOR ALL INDIVIDUD/OR ENTERPRISE OWNERS PRTNERS SHEHOLDERS OFFICERS |
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D RESPONSIBLE PRTIES. IF STOCK IS PUBLICLY |
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TRED PROVIDE THE FOLLOWING FOR ANY SHAREHOLDER WITH AN EQUITY POSITION OF 5% OR MORE ADDITIONAL SPACE IS AVAILABLE IN SECTION 6A, PAGE 11 |
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DTE OF BIRTH * |
4. FEDER EIN |
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5. |
OWNER |
OFFICER |
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6. TITLE |
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. EFFECTIVE DTE |
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PERCENTE OF |
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VE DTE OF |
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PRTNER |
SHEHOLDER |
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OF TITLE |
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OWNERSHIP |
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OWNERSHIP |
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RESPONSIBLE PRTY |
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% |
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. HOME DRESS reet |
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CITY/TOWN |
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COUNTY |
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STTE |
ZIP CODE + 4 |
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. THIS PERSON IS RESPONSIBLE TO REMIT/MNTN: |
SES T |
EMPLOYER WITHHOLDING TX |
MOTOR FUEL T |
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WORKERSʼ COMPENSTION COVERE |
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* DTE OF BIRTH REQUIRED ONLY IFYING FOR CIGETTE WHOL |
ESE DEERʼS LICENSE SML GOF CHCE DISTRIBUTOR LICENSE OR SML |
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OF CHCE MUFTURER CERTIFICTE. |
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SECTION 7 – ESTABLISHMENT BUSINESS ACTIVITY INFORMATION |
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REFER TO THE INSTRUCTIONS ON PAGES 20 & 21 TO COMPLETE THIS SECTION COMPLETE SECTION 17 FOR MULTIPLE ESTABLISHMENTS |
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. ENTER THE PERCENTE THT EH |
PABUSINESS ACTIVITY REPRESENTS OF THE TOTL RECEIPTS OR REVENUEST |
THIS ESTISHMENT. LIST |
PRODUCTS OR |
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SERVICES CITED WITH EH BUSINESS TIVITY D THE PERCENTE REPRESENTING THE TO |
TL RECEIPTS OR REVENUES. |
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PA BUSINESS ACTIVITY |
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PRODUCTS OR SERVICES |
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ADDITIONAL |
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PRODUCTS OR SERVICES |
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mmodation & Food Services
riculture Forestry Fishing & Hunting
Entertainment & Recreation Services
Communications/Information
Construction st complete question
Domestics vate Households
Educational Services
Finance
Health Care Services
Insurance
Management Support & Remediation Services
Manufacturing
Mining Quarrying & Oil/Gas Extraction
Other Services
Professional Scientific & Technical Services
Public ministration
Real Estate
Retail Trade
Sanitary Service
Social stance Services
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Transportation |
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Utilities |
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Warehousing |
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Wholesale Trade |
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TOTL |
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% |
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. ENTER THE PERCENTE THT |
THIS ESTABLISHMENTS RECEIPTS OR REVENUES REPRESENT OF THE TOTAL PARECEIPTS OR REVENUES OF THE ENTERPRISE. |
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______________%. SINGLE ESTBLISHMENT ENTERPRI SES ENTER %. MULTIPLE ESTISHMENT ENTERPRISES ENTER PERCENTE OF ENTERPRISE SEC |
TION |
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. ESTISHMENTS ENGED IN CONSTRUCTION |
MUST ENTER THE PERCENTE OF CONSTRUCTION TIVITY THT IS NEW D/OR |
RENOVTIVE D THE PERCENT |
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E OF CONSTRUCTION TIVITY THT IS RESIDENTID/OR COMMERCI |
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___________________% NEW |
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__________________% RENOVTIVE |
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% |
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___________________% RESIDENTIL |
+ |
__________________% COMMERCIL |
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% |
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4. YES NO |
DOES THIS ENTERPRISE WNT TO BECOME PENNSYLVNILOTTERY |
RETLER? |
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PA-100 (03-09) |
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DEPRTMENT USE ONLY |
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ENTERPRISE N |
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SECTION 8 – ESTABLISHMENT SALES INFORMATION
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YES |
NO |
IS THIS ESTISHMENT SELLING TE PRODUCTS OR OFFERING TE SERVICES TO |
CONSUMERS FROM LOCTION |
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IN PENNSYLVANIA? IF YES COMPLETE SECTION . |
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YES |
NO |
IS THIS ESTISHMENT SELLING CIGETTES |
IN PENNSYLVANIA? IF YES COMPLETE SECTIONS D . |
. LIST EH COUNTY |
IN PENNSYLVANIA WHERE THIS ESTISHMENT IS CONDUCTING TE SES TIVITYES |
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COUNTY |
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COUNTY |
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COUNTY |
COUNTY |
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COUNTY |
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COUNTY |
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ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY. |
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SECTION 9 – ESTABLISHMENT EMPLOYMENT INFORMATION
PART 1
NO |
DOES THIS ESTISHMENT EMPLOY INDIVIDUS WHO |
WORK IN PENNSYLVANIA? IF YES INDICTE: |
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a. |
DTE WES FIRST |
PAID DD/YYYY |
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b. |
DTE WGES RESUMED FOLLOWING BREIN EMPLOYMENT |
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c. |
TOTL NUMBER OF EMPLOYEES |
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d. |
NUMBER OF EMPLOYEES PRIMILY WORKING IN NEW BUILDING OR INFRRUC |
TURE |
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e.NUMBER OF EMPLOYEES PRIMILY WORKING IN REMODELING CONSTRUCTION . . . . . . . . . . . . . . . . . . . . . .
f. ESTIMTED GROSS WGES PER QUTER |
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . .$ |
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g.NOF WORKERSʼ COMPENSTION INSURCE COMPY
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POLICY NUMBER _________________________________E FFECTIVE STRT DTE __________________END DTE __ |
_________________ |
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GENCY NME _____________________________________ _________________DYTIME TELEPHONE NU MBER ______________________ |
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MLING DRESS |
_____________________________________CITY/TOWN ______________________STTE _____ZIP CODE + 4_ _______ |
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IF THIS ENTERPRISE DOES NOT HVE WORKERSʼ COMPENSTIONINSURCE CHECK |
ONE: |
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a. |
THIS ESTISHMENT EMPLOYSONLY EXCLUDED WORKERS . . . . |
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b. |
. . . . . . . . . . . . . .THIS ESTISHMENT HZERO EMPLOYEES |
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c.THIS ESTISHMENT RECEIVED OVTO SELFNSURE BY THE PBURE OF
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WORKERSʼ COMPENSTION |
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IF ITEM c. IS CHECKED PROVIDE PWORKERSʼ COMPENSTION BURE CODE |
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NO |
DOES THIS ESTISHMENT EMPLOY PRESIDENTS WHO |
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WORK OUTSIDE OF PENNSYLVANIA? |
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IF YES INDICTE: |
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a. |
DTE WES FIRST |
PAID DD/YYYY . . . |
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b. |
. . . . . . . .DTE WGES RESUMED FOLLOWING BREIN EMPLOYMENT |
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c. |
ESTIMTED GROSS WGES PER QUTER. |
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NO |
DOES THIS ESTISHMENT PY REMUNERTION FOR SERVICES TO PERSONS YOU DO |
NOT CONSIDER EMPLOYEES? |
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IF YES EXPLN THE SERVICES PERFORMED |
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PART 2
. YES |
NO |
IS THIS REGISTRTION |
RESULT OF TE DISTRIBUTION FROM |
BENEFIT TRUST DEFERRED PYMENT OR RETIREMENT PL |
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FOR PRESIDENTS? |
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IF YES INDICTE: |
a. |
DTE BENEFITS FIRST PAID DD/YYYY |
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b. ESTIMTED BENEFITS PID PER QUTER |
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SECTION 10 – BULK SALE/TRANSFER INFORMATION |
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IF S WERE QUIRED IN BULK FROM MORE TH ONE ENTERPRISE PHOTOCOPY T |
HIS SECTION D PROVIDE THE FOLLOWING INFORMTION |
UT EH |
SELLER/TRSFEROR. |
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YES |
NO |
DID THE ENTERPRISE QUIRE 5% OR MORE OF |
ANY CLASS OF THE PA ASSETS OF OTHER ENTERPRISE? SEE THE CLOF S |
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LISTED BELOW. |
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YES |
NO |
DID THE ENTERPRISE QUIRE 5% OR MORE OF THE |
TOTALASSETS OF OTHER ENTERPRISE? |
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IF THE SWER TO EITHER QUESTION IS YES PROVIDE THE FOLLOWING INFO RMTION UT THE |
SELLER/TRANSFEROR |
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. SELLER/TRSFEROR N |
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4. FEDER EIN |
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5. SELLER/TRSFEROR STREETDRESS
6. DTE S QUIRED |
. S QUIRED: |
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COUNTS RECEIVE |
EQUIPMENT |
INVENTORY |
ND/OR GOODWILL |
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CONTRTS |
FIXTURES |
LE |
RE ESTTE |
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CUSTOMERS/CLIENTS |
FURNITURE |
MHINERY |
OTHER |
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IMPORTANT: IF, IN ADDITION TO ACQUIRING ASSETS IN BULK, THE ENTERPRISE ALSO ACQUIRED ALL OR PART OF A PREDECESSOR'S BUSINESS, SECTION 14 MUST BE COMPLETED.
IF THE ENTERPRISE IS ACQUIRING 51% OR MORE OF ANY CLASS OF PA ASSETS AND/OR 51% OF THE TOTAL ASSETS OF ANOTHER ENTERPRISE THE SELLER MUST OBTAIN A BULK SALE CLEARANCE CERTIFICATE. REFER TO INSTRUCTIONS ON PAGE 22.
PA-100 (03-09) |
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DEPRTMENT USE ONLY |
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ENTERPRISE N |
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SECTION 11 – CORPORATION INFORMATION
. DTE OF INCORPORTION |
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STTE OF INCORPORTION |
. CERTIFIC |
TE OF THORITY DTE |
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ONCORP. |
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4. COUNTRY OF INCORPORTION
5. |
YES |
NO |
IS THIS CORPORTION'S STOCK PUBLICLY TRED? |
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6. |
CHECK THE OPRITE BOX TO DESCRIBE THIS CORPORTION: |
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CORPORTION: |
STOCK |
PROFESSION |
BK: |
STTE |
MUTU |
THRIFT: STTE |
INSURCE |
P |
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NONOCK |
COOPERTIVE |
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FEDER |
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FEDER |
COMPNY: |
NON |
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MEMENT |
STTUTORY CLOSE |
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. S CORPORTION: |
FEDER |
INCORDCE WITHT NO.6 OF 6 CORPORTION WITH |
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FEDER SUBHER S STTUS IS CONSIDERED PS COR |
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PORTION. IN ORDER |
NOT TO BE T P S CORPORTION REV6 |
MUST BE FILED. THE FORM C BE CESSED T |
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WWWREVENUESTATEPAUS FORMS D PUBLICTIONS CORPORTION T |
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COMPLETING THIS FORM WILL NOT FULFILL THE REQUIREMENT TO REGISTER FOR CORPORATE TAXES REGISTERING CORPORATIONS MUST CONTACT THE PA DEPART- MENT OF STATE TO SECURE CORPORATE NAME CLEARANCE AND REGISTER FOR CORPORATION TAX PURPOSES CONTACT THE PA DEPARTMENT OF STATE AT (717) 787- 1057, OR VISIT wwwaoeforbusiessstateaus
SECTION 12 – REPORTING & PAYMENT METHODS
. THE DEPRTMENT OF REVENUE REQUIRES THTY ENTERPRISEMNG PYMENTS EQ |
U TO OR GRETER TH $ REMIT PYMENTS VI ONE |
OF THE FOL |
LOWING ELECTRONIC METHODS: ELECTRONIC FUNDS TRSFER T ELECTRO |
NIC TINFORMTION D DTEXCHGE SYSTEM IDES TELEFILE SYSTEM OR |
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CREDIT CD. ENTERPRISE REGDLESS OF UNTIS ENCOURED TO REMIT |
TPYMENTS ELECTRONICLY. |
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NO |
DOES THIS ENTERPRISE MEET THE DEPRTMENT OF REVENUEʼS REQUIREMENTS FOR ELECT RONIC PYMENTS? |
NO |
DOES THIS ENTERPRISE WNT TO PRTICIPTE IN THE DEPRTMENT OF |
REVENUEʼS ELECTRONIC PROGR |
NO |
IF THIS ENTERPRISE IS NONOFIT ORGIZTION THT IS EXEMPT UN |
DER IRC 5 OR POLITIC SUBIVISIONS IS IT |
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INTERESTED IN RECEIVING INFORMTION UT THE DEPRTMENT OF LR & |
INDUSTRYʼS OPTION OF FINCING UC COSTS |
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UNDER THE REIMBURSEMENT METHOD IN LIEU OF THE CONTRIBUTORY METHOD? FOR MORE DETILS REFER TO SECTION |
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INSTRUCTIONS. |
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THE DEPRTMENT OF LR & INDUSTRY REQUIRES THTY ENTERPRISE WITH |
5 OR MORE WGE ENTRIES PER QUTERLY REPORTFILE THE W |
GE INFORMTION VI |
MNETIC MEDIY MNETIC REPORTING FILE MUST BE SUBMITTED FOR COMPTI |
BILITY WITH THE DEPRTMENT OF LR & INDUSTRYʼS FORMT. CONTT |
THE M |
NETIC MEDI REPORTING UNITT FOR MORE INFORMT |
ION. |
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THE COMMONWETH STRONGLY RECOMMENDS THT ENTERPRISES USE ELECTRONIC FIL |
ING D PYMENT OPTIONS FOR CERTN PENNSYLVNI TD SERVICES. |
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INFORMTION UT INTERNET FILING OPTIONS C BE FOUND ON THE |
eIDES WEB SITET |
wwwetidesstateaus |
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SECTION 13 – GOVERNMENT STRUCTURE
. IS THE ENTERPRISE |
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GOVERNMENT BODY |
GOVERNMENT OWNED ENTERPRISE |
GOVERNMENT & PRIVTE SECTOR |
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OWNED ENTERPRISE |
. IS THE GOVERNMENT: |
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DOMESTIC/US |
FOREIGN/NONS |
MULTITION |
. IF DOMESTIC IS THE GOVERNMENT: |
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FEDER |
LOC: |
COUNTY |
BOROUGH |
STTE GOVERNOR'S JURISDICTION |
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CITY |
SCHOOL DISTRICT |
STTE NONOVERNOR'S JURISDICTION |
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TOWN |
OTHER |
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|
TOWNSHIP |
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