REV-181 (CM), Application for Tax Clearance Certificate (Pennsylvania Department of Revenue) Instructions

Enter the full name of the prior business entity from which any assets or activities were acquired, if applicable.

Provide the original signature of the authorized individual for the application.

Provide the original signature of the authorized individual for the application.

Provide a detailed description of the business activity conducted in Pennsylvania, including services performed and rendered, principal commodities sold at wholesale or retail, and any relevant sales or construction activities; specify if manufacturers' representatives or independent contractors perform work on behalf of the entity and describe those activities.

Enter the full legal name of the business as it appears on registration documents or tax records.

Enter the business federal EIN exactly as assigned by the IRS (include any hyphen).

Enter the business's current mailing address: P.O. Box, street and number, or R.D. number and box number as applicable.

Enter the business telephone number for this mailing address, including area code if required.

Enter the city or town of the business's current mailing address.

Enter the county in which the business's mailing address is located.

Enter the state for the business mailing address (use the standard state name or postal abbreviation).

Enter the postal ZIP code for the business's current mailing address.

Enter the full printed name of the first signer certifying this form (the person who will sign the certification).

Enter the full printed name of the second signer exactly as they wish it to appear on the certification.

Enter the full name of the attorney or authorized representative to whom the clearance certificate should be sent. Fill only if 'Business Mailing Address (P.O. Box / Street & Number / R.D. No.)', 'City or Town', 'County', 'State', 'ZIP Code' is different from where the Clearance Certificate should be sent.

Enter the daytime telephone number for the attorney or representative, including area code and extension if applicable. Fill only if 'Business Mailing Address (P.O. Box / Street & Number / R.D. No.)', 'City or Town', 'County', 'State', 'ZIP Code' is different from where the Clearance Certificate should be sent.

Enter the mailing address where the clearance certificate should be sent, such as P.O. Box, street number and name, or R.D. number and box number. Fill only if 'Business Mailing Address (P.O. Box / Street & Number / R.D. No.)', 'City or Town', 'County', 'State', 'ZIP Code' is different from where the Clearance Certificate should be sent.

Enter the city or town portion of the attorney/representative's mailing address. Fill only if 'Business Mailing Address (P.O. Box / Street & Number / R.D. No.)', 'City or Town', 'County', 'State', 'ZIP Code' is different from where the Clearance Certificate should be sent.

Enter the county for the attorney/representative's mailing address. Fill only if 'Business Mailing Address (P.O. Box / Street & Number / R.D. No.)', 'City or Town', 'County', 'State', 'ZIP Code' is different from where the Clearance Certificate should be sent.

Enter the state for the attorney/representative's mailing address (use the two-letter abbreviation or full state name). Fill only if 'Business Mailing Address (P.O. Box / Street & Number / R.D. No.)', 'City or Town', 'County', 'State', 'ZIP Code' is different from where the Clearance Certificate should be sent.

Enter the ZIP Code for the attorney/representative's mailing address (include ZIP+4 if available). Fill only if 'Business Mailing Address (P.O. Box / Street & Number / R.D. No.)', 'City or Town', 'County', 'State', 'ZIP Code' is different from where the Clearance Certificate should be sent.

Use this button to select the date in MM/DD/YYYY format.

Enter the Pennsylvania Department of Revenue assigned Revenue ID or account number for the business as printed by the department.

Enter the date the corporation was originally incorporated in Pennsylvania. Fill only if 'Domestic Corporation (Incorporated in PA)' is 'Yes'.

Enter whether the entity had employees for whom Pennsylvania personal income tax was required to be withheld from wages (for example, 'Yes' or 'No'); if answering 'Yes', include any relevant details such as dates, number of employees, or brief explanation.

Enter the full legal name of the first responsible party (individual, owner, or officer) as it should appear on official records.

Enter the first responsible party's Social Security Number (SSN), including dashes if customarily used.

Enter the telephone number for the first responsible party, including area code and extension if applicable.

Enter the first responsible party's mailing address: street address, P.O. Box, or R.D. number and box number.

Enter the city or town for the first responsible party's mailing address.

Enter the state for the first responsible party's mailing address (use the two-letter abbreviation or full state name).

Enter the ZIP code for the first responsible party's mailing address (5-digit ZIP or ZIP+4).

Enter the name or two-letter postal abbreviation of the U.S. state or foreign jurisdiction where the corporation was originally incorporated. Fill only if 'Foreign Corporation (not incorporated in PA)' is 'Yes'.

Provide the date on which the corporation was issued its Certificate of Authority to do business in Pennsylvania. Fill only if 'Foreign Corporation (not incorporated in PA)' is 'Yes'.

Check this box if you are requesting a Foreign Corporation Clearance Certificate under the provisions of the Act of 1947, P.L. 493 in connection with a contract number and/or a political subdivision.

Enter the full name of the person or official authorizing the PA Department of Revenue to disclose requested tax and filing information for the contract/political subdivision. Fill only if 'F. Foreign Corporation Clearance Certificate (Act of 1947, P.L. 493) - Contract/Political Subdivision' is 'Yes'.

Check this box if the filing entity is a foreign corporation and it has terminated (ceased) its business in its state of incorporation. Fill only if 'Type of Business' is 'FOREIGN CORPORATION (not incorporated in PA)'.

Check this box if the filing entity is a foreign corporation and it has NOT terminated (ceased) its business in its state of incorporation. Fill only if 'Type of Business' is 'FOREIGN CORPORATION (not incorporated in PA)'.

Click this button to print the form.

Click this button to proceed to the next page of the form.

Button to reset the entire form to its default state.

This button is used to start the form process. It may not require any input.

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Click this button to go back to the previous page of the form.

Check this box if the taxpayer has ever held a Corporation Tax license, permit, or account with the Commonwealth of Pennsylvania (if checked, also provide the period and Revenue ID number).

Check this box if the taxpayer has never held a Corporation Tax license, permit, or account with the Commonwealth of Pennsylvania.

Enter the starting date of the period for the Corporation Tax license being reported for row (a). Fill only if 'Row (a) Corporation Tax - Yes' is 'Yes'.

Enter the ending date of the period for the Corporation Tax license being reported for row (a). Fill only if 'Row (a) Corporation Tax - Yes' is 'Yes'.

Enter the Revenue ID number associated with the Corporation Tax license for row (a). Fill only if 'Row (a) Corporation Tax - Yes' is 'Yes'.

Check this box if the taxpayer ever held a malt beverage or liquor license, permit, or account with the Commonwealth of Pennsylvania (answer = Yes).

Check this box if the taxpayer never held a malt beverage or liquor license, permit, or account with the Commonwealth of Pennsylvania (answer = No).

Enter the beginning date of the Malt Beverage or Liquor License period for license row (b). Fill only if 'Malt Beverage or Liquor License (b) - Yes' is 'Yes'.

Enter the ending date of the Malt Beverage or Liquor License period for license row (b). Fill only if 'Malt Beverage or Liquor License (b) - Yes' is 'Yes'.

Enter the Malt Beverage or Liquor License number assigned to the business for license row (b). Fill only if 'Malt Beverage or Liquor License (b) - Yes' is 'Yes'.

Check this box if the taxpayer previously held a Liquid Fuels license, permit, or account with the Commonwealth of Pennsylvania.

Check this box if the taxpayer never held a Liquid Fuels license, permit, or account with the Commonwealth of Pennsylvania.

Enter the beginning date of the reporting period for the Liquid Fuels license row. Fill only if 'Liquid Fuels (c) — Yes' is 'Yes'.

Enter the ending date of the reporting period for the Liquid Fuels license row. Fill only if 'Liquid Fuels (c) — Yes' is 'Yes'.

Enter the permit number assigned for the Liquid Fuels license (provide letters and/or numbers exactly as they appear). Fill only if 'Liquid Fuels (c) — Yes' is 'Yes'.

Check this box if the taxpayer EVER held a Cigarette Tax license, permit, or account with the Commonwealth of Pennsylvania (provide the period and license number where requested).

Check this box if the taxpayer NEVER held a Cigarette Tax license, permit, or account with the Commonwealth of Pennsylvania.

Enter the beginning date of the Cigarette Tax license/permit period. Fill only if 'License Row (d) Cigarette Tax - Yes' is 'Yes'.

Enter the ending date of the Cigarette Tax license/permit period. Fill only if 'License Row (d) Cigarette Tax - Yes' is 'Yes'.

Enter the Cigarette Tax license number issued by the Commonwealth of Pennsylvania. Fill only if 'License Row (d) Cigarette Tax - Yes' is 'Yes'.

Check this box if the taxpayer ever held a Sales, Use and Hotel Occupancy Tax license, permit, or account with the Commonwealth of Pennsylvania.

Check this box if the taxpayer never held a Sales, Use and Hotel Occupancy Tax license, permit, or account with the Commonwealth of Pennsylvania.

Enter the beginning date of the tax reporting period for the Sales, Use and Hotel Occupancy Tax associated with row (e). Fill only if 'Sales, Use and Hotel Occupancy Tax (e) — Yes' is 'Yes'.

Enter the ending date of the tax reporting period for the Sales, Use and Hotel Occupancy Tax associated with row (e). Fill only if 'Sales, Use and Hotel Occupancy Tax (e) — Yes' is 'Yes'.

Enter the license, permit, or account number assigned for the Sales, Use and Hotel Occupancy Tax referenced in row (e). Fill only if 'Sales, Use and Hotel Occupancy Tax (e) — Yes' is 'Yes'.

Check this box if the taxpayer ever held a Motor Carrier license, permit, or account with the Commonwealth of Pennsylvania (and complete the associated period and license/account number fields).

Check this box if the taxpayer never held a Motor Carrier license, permit, or account with the Commonwealth of Pennsylvania.

Enter the beginning date of the time period for which the Motor Carrier license, permit or account was held. Fill only if 'Motor Carrier — Yes' is 'Yes'.

Enter the ending date of the time period for which the Motor Carrier license, permit or account was held. Fill only if 'Motor Carrier — Yes' is 'Yes'.

Enter the Motor Carrier license or account number issued by the Commonwealth of Pennsylvania. Fill only if 'Motor Carrier — Yes' is 'Yes'.

Check this box if the taxpayer ever held a Fuel Dealer-User license, permit, or account with the Commonwealth of Pennsylvania (enter the applicable period and license number in the adjacent fields).

Check this box if the taxpayer never held a Fuel Dealer-User license, permit, or account with the Commonwealth of Pennsylvania.

Enter the beginning date of the reporting or licensing period for the Fuel Dealer-User account. Fill only if 'g Fuel Dealer-User – Yes' is 'Yes'.

Enter the ending date of the reporting or licensing period for the Fuel Dealer-User account. Fill only if 'g Fuel Dealer-User – Yes' is 'Yes'.

Enter the license, permit, or account number assigned to the Fuel Dealer-User by the Commonwealth of Pennsylvania. Fill only if 'g Fuel Dealer-User – Yes' is 'Yes'.

Check this box if the taxpayer has ever held a Lottery license, permit, or account with the Commonwealth of Pennsylvania.

Check this box if the taxpayer has never held a Lottery license, permit, or account with the Commonwealth of Pennsylvania.

Enter the starting date or beginning of the coverage period for the lottery license or account being reported. Fill only if 'Lottery — Yes' is 'Yes'.

Enter the ending date or conclusion of the coverage period for the lottery license or account being reported. Fill only if 'Lottery — Yes' is 'Yes'.

Provide the agent number associated with the lottery license or account as assigned by the Commonwealth (enter the identifier shown on your records). Fill only if 'Lottery — Yes' is 'Yes'.

Check this box if the taxpayer ever held a Small Games of Chance Manufacturer or Distributor license, permit, or account with the Commonwealth of Pennsylvania (answer = Yes).

Check this box if the taxpayer never held a Small Games of Chance Manufacturer or Distributor license, permit, or account with the Commonwealth of Pennsylvania (answer = No).

Enter the beginning date of the licensing period for Small Games of Chance manufacturing/distributing in the Commonwealth. Fill only if '(i) Small Games of Chance Mfg./Distr. — Yes' is 'Yes'.

Enter the ending date of the licensing period for Small Games of Chance manufacturing/distributing in the Commonwealth. Fill only if '(i) Small Games of Chance Mfg./Distr. — Yes' is 'Yes'.

Provide the license or account number assigned for the Small Games of Chance manufacturing/distributing activity. Fill only if '(i) Small Games of Chance Mfg./Distr. — Yes' is 'Yes'.

Check this box if the taxpayer EVER held a Public Transportation Assistance license, permit, or account with the Commonwealth of Pennsylvania.

Check this box if the taxpayer NEVER held a Public Transportation Assistance license, permit, or account with the Commonwealth of Pennsylvania.

Enter the beginning date of the period for which the Public Transportation Assistance license or account applied. Fill only if '(j) Public Transportation Assistance - Yes' is 'Yes'.

Enter the ending date of the period for which the Public Transportation Assistance license or account applied. Fill only if '(j) Public Transportation Assistance - Yes' is 'Yes'.

Enter the license or account number assigned for the Public Transportation Assistance program (alphanumeric as issued). Fill only if '(j) Public Transportation Assistance - Yes' is 'Yes'.

Check this box if the taxpayer EVER held a Pennsylvania Unemployment Compensation account, license, or permit (provide the period and account number in the adjacent fields).

Check this box if the taxpayer NEVER held a Pennsylvania Unemployment Compensation account, license, or permit.

Enter the starting date of the PA Unemployment Compensation coverage or license period being reported for row (k). Fill only if 'License Row (k) PA Unemployment Compensation - Yes' is 'Yes'.

Enter the ending date of the PA Unemployment Compensation coverage or license period being reported for row (k). Fill only if 'License Row (k) PA Unemployment Compensation - Yes' is 'Yes'.

Enter the PA Unemployment Compensation account number associated with the entity for row (k). Fill only if 'License Row (k) PA Unemployment Compensation - Yes' is 'Yes'.

Check this box if the taxpayer ever held a Pennsylvania Oil Company Franchise Tax license, permit, or account with the Commonwealth of PA (i.e., answer 'Yes').

Check this box if the taxpayer never held a Pennsylvania Oil Company Franchise Tax license, permit, or account with the Commonwealth of PA (i.e., answer 'No').

Enter the start date of the tax period for the PA Oil Company Franchise Tax being reported. Fill only if 'License Row (l) PA Oil Company Franchise Tax - Yes' is 'Yes'.

Enter the end date of the tax period for the PA Oil Company Franchise Tax being reported. Fill only if 'License Row (l) PA Oil Company Franchise Tax - Yes' is 'Yes'.

Enter the PA Oil Company Franchise Tax account number assigned by the Commonwealth for this entity. Fill only if 'License Row (l) PA Oil Company Franchise Tax - Yes' is 'Yes'.

Enter the P.O. Box or street address and number where the business records are located.

Enter the city or town of the business records location.

Enter the state of the business records location (state abbreviation or full name).

Enter the postal ZIP Code for the business records location (5-digit or ZIP+4 as applicable).

Enter a telephone number where the business records can be reached, including area code.

Check this box if the business engaged in the sale of soft drinks or soft drink syrup within the Commonwealth of Pennsylvania during the reported period.

Check this box if the business did not engage in the sale of soft drinks or soft drink syrup within the Commonwealth of Pennsylvania during the reported period.

Enter the starting date or starting period (e.g., month/day/year or year) that marks the beginning of the time range during which the business engaged in the sale of soft drinks or soft drink syrup. Fill only if 'Row (a) Soft Drinks/Syrup - Yes' is 'Yes'.

Enter the ending date or ending period (e.g., month/day/year or year) that marks the end of the time range during which the business engaged in the sale of soft drinks or soft drink syrup. Fill only if 'Row (a) Soft Drinks/Syrup - Yes' is 'Yes'.

Check this box if, within the Commonwealth of Pennsylvania, the business does or did own or lease and operate diesel-powered motor vehicles on Pennsylvania highways during the period being reported.

Check this box if, within the Commonwealth of Pennsylvania, the business has not owned, leased, or operated diesel-powered motor vehicles on Pennsylvania highways during the period being reported.

Enter the start date of the period during which the business owned or leased and operated diesel-powered motor vehicles on Pennsylvania highways. Fill only if 'Row (b) Own or lease and operate diesel-powered motor vehicles on PA highways — Yes' is 'Yes'.

Enter the end date of the period during which the business owned or leased and operated diesel-powered motor vehicles on Pennsylvania highways. Fill only if 'Row (b) Own or lease and operate diesel-powered motor vehicles on PA highways — Yes' is 'Yes'.

Check this box if the business engaged in the sale of diesel fuel to motor vehicles using Pennsylvania highways during the period in question.

Check this box if the business did not engage in the sale of diesel fuel to motor vehicles using Pennsylvania highways during the period in question.

Enter the starting date when the business began engaging in the sale of diesel fuel to motor vehicles using Pennsylvania highways. Fill only if '(c) Diesel Fuel Sales - Yes' is 'Yes'.

Enter the ending date when the business ceased (or most recently engaged in) the sale of diesel fuel to motor vehicles using Pennsylvania highways. Fill only if '(c) Diesel Fuel Sales - Yes' is 'Yes'.

Check this box if the business engaged in the sale or lease of tangible personal property in Pennsylvania at any time since September 1, 1953.

Check this box if the business did not engage in the sale or lease of tangible personal property in Pennsylvania at any time since September 1, 1953.

Enter the starting year or date for the period when the business engaged in the sale or lease of tangible personal property (the left-hand 'Period' value). Fill only if 'Row (d) Tangible Personal Property since 9/1/1953 - Yes' is 'Yes'.

Enter the ending year or date for the period when the business engaged in the sale or lease of tangible personal property (the right-hand 'Period' value). Fill only if 'Row (d) Tangible Personal Property since 9/1/1953 - Yes' is 'Yes'.

Check this box if the business has filed Pennsylvania Unemployment Compensation reports (answer is Yes).

Check this box if the business has not filed Pennsylvania Unemployment Compensation reports (answer is No).

Enter the starting date of the reporting period for PA Unemployment Compensation reports covered by row (e). Fill only if '15(e) File PA Unemployment Compensation Reports? — Yes' is 'Yes'.

Enter the ending date of the reporting period for PA Unemployment Compensation reports covered by row (e). Fill only if '15(e) File PA Unemployment Compensation Reports? — Yes' is 'Yes'.

Enter the Pennsylvania account number referenced in question 15 (provide the full account number assigned by the PA Department of Revenue or Unemployment Compensation if you answered "Yes"). Fill only if '15(e) File PA Unemployment Compensation Reports? — Yes' is 'Yes'.

Enter the date the business began operating in Pennsylvania.

Enter the date the business ceased operations in Pennsylvania, or leave blank if the business is still operating.

Provide a concise description of any matters currently pending with the Pennsylvania Department of Revenue, including case or petition numbers (if known), filing or hearing dates, current status, and a brief explanation of the issue or relief sought.

Check this box if the assets or activities of the business were acquired, in whole or in part, from a prior business entity (if checked, provide predecessor's name, address and acquisition date in the fields below).

Check this box if the assets or activities of the business were not acquired from a prior business entity.

Enter the full legal name of the prior (predecessor) business from which assets or activities were acquired. Fill only if 'Prior Business Acquisition - Yes' is 'Yes'.

Provide the date on which the predecessor business was acquired. Fill only if 'Prior Business Acquisition - Yes' is 'Yes'.

Enter the predecessor business's mailing address including P.O. Box (if any), street name and street number. Fill only if 'Prior Business Acquisition - Yes' is 'Yes'.

Enter the city or town for the predecessor business's address. Fill only if 'Prior Business Acquisition - Yes' is 'Yes'.

Enter the county in which the predecessor business is located. Fill only if 'Prior Business Acquisition - Yes' is 'Yes'.

Enter the state (or territory) for the predecessor business's address. Fill only if 'Prior Business Acquisition - Yes' is 'Yes'.

Enter the ZIP or postal code for the predecessor business's address. Fill only if 'Prior Business Acquisition - Yes' is 'Yes'.

Check this box when you are requesting a clearance certificate because the corporation or association is being dissolved through the Department of State.

Check this box when the corporation or association is being dissolved through the Court of Common Pleas (also provide the date the court was petitioned and the county).

Enter the date the Court of Common Pleas was petitioned for the dissolution of the corporation or association. Fill only if 'B. Dissolution of Corporation or Association through Court of Common Pleas' is 'Yes'.

Enter the name of the county where the Court of Common Pleas petition for dissolution was filed. Fill only if 'B. Dissolution of Corporation or Association through Court of Common Pleas' is 'Yes'.

Check this box when you are withdrawing a foreign corporation from Pennsylvania through the Department of State and need a clearance certificate for that withdrawal.

Check this box when the purpose is a merger or consolidation and the surviving corporation or association will not be subject to Pennsylvania jurisdiction.

Check this box when requesting a clearance certificate for a bulk sale under Section 1403 of the Fiscal Code (provide sale date and attach a copy of the settlement statement).

Enter the date of the sale for the Bulk Sale Clearance Certificate under Section 1403 of the Fiscal Code. Fill only if 'E. Bulk Sale Clearance Certificate under Section 1403 of the Fiscal Code' is 'Yes'.

Check this box when the clearance certificate is being requested specifically for corporation tax purposes.

Check this box when the clearance certificate is needed for employer withholding tax purposes.

Check this box when the clearance certificate is required for sales, use, or hotel occupancy tax purposes.

Check this box when the clearance certificate is being requested for unemployment compensation tax purposes.

Provide the calendar year for the fifth (most distant) reporting year as shown to the Social Security Administration.

Enter the total number of employees for the fifth reporting year as reported to the Social Security Administration.

Enter the number of employees working in Pennsylvania for the fifth reporting year as reported to the Social Security Administration.

Enter the total gross payroll amount for all employees for the fifth reporting year as reported to the Social Security Administration.

Enter the portion of gross payroll attributable to Pennsylvania employees for the fifth reporting year as reported to the Social Security Administration.

Enter the four-digit calendar year for the first row (e.g., 2020) as reported to the Social Security Administration.

Enter the total number of employees for the first year as reported to the Social Security Administration.

Enter the number of employees working in Pennsylvania (PA) during the first year as reported to the Social Security Administration.

Enter the total gross payroll for all employees for the first year as reported to the Social Security Administration.

Enter the portion of gross payroll attributable to Pennsylvania employees for the first year as reported to the Social Security Administration.

Enter the calendar year for the fourth year in the payroll history as reported to the Social Security Administration.

Enter the total number of employees for the fourth year as reported to the Social Security Administration.

Enter the number of employees working in Pennsylvania for the fourth year as reported to the Social Security Administration.

Enter the total gross payroll for all employees for the fourth year as reported to the Social Security Administration.

Enter the gross payroll attributable to employees in Pennsylvania for the fourth year as reported to the Social Security Administration.

Enter the calendar year for the second payroll history row (e.g., 2024).

Enter the total number of employees for that year as reported to the Social Security Administration.

Enter the number of employees based in Pennsylvania for that year as reported to the Social Security Administration.

Provide the total gross payroll for all employees for that year as reported to the Social Security Administration.

Provide the total gross payroll attributable to Pennsylvania employees for that year as reported to the Social Security Administration.

Enter the calendar year for the third row of payroll history as reported to the Social Security Administration.

Enter the total number of employees for the third year as reported to the Social Security Administration.

Enter the number of employees working in Pennsylvania for the third year as reported to the Social Security Administration.

Enter the company's total gross payroll for the third year as reported to the Social Security Administration.

Enter the portion of gross payroll attributable to Pennsylvania for the third year as reported to the Social Security Administration.

Check this box if any officers received remuneration, in cash or other form, for services performed in Pennsylvania during the current calendar year or any of the preceding four calendar years.

Check this box if no officers received any remuneration for services performed in Pennsylvania during the current calendar year or any of the preceding four calendar years.

Check this box if there were remunerated services performed for the business in Pennsylvania that you believe did not constitute “employment” under the PA Unemployment Compensation Law.

Check this box if there were no remunerated services performed for the business in Pennsylvania that you believe fell outside the PA Unemployment Compensation Law’s definition of employment.

Provide a clear description of the services performed in Pennsylvania that you believe did not constitute 'employment' under the PA Unemployment Compensation Law, including relevant details such as who performed the services, nature of the work, dates or time periods, and any facts supporting why the services were not employment. Fill only if 'Q19 Yes' is 'Yes'.

Enter the average number of stockholders the corporation had over the last five years.

Enter the total number of stockholders who hold the corporation's stock as of the date of this report.

Enter the full name of the first stock transfer agent who handled the corporation’s stock (e.g., individual or firm name).

Enter the home or business mailing address of that first stock transfer agent, including street, city, state, and ZIP code.

Enter the full name of the second stock transfer agent who handled the corporation’s stock.

Enter the mailing address (street, city, state, ZIP) for the second stock transfer agent listed.

Enter the full name of the third stock transfer agent who has handled the corporation’s stock (first and last name or business name).

Enter the complete mailing address for the third stock transfer agent, including street, city, state, and ZIP code.

Check this box if all shares presented and property were redeemed from any stock called for redemption or retired.

Check this box if not all shares presented and property were redeemed from any stock called for redemption or retired (i.e., some were not redeemed/retired).

Provide the date of the corporate tax report filed with the Pennsylvania Department of Revenue that these figures must agree with.

Enter the total liabilities amount reported on the corporate tax report filed with the Pennsylvania Department of Revenue.

Enter the total assets amount reported on the corporate tax report filed with the Pennsylvania Department of Revenue.

Enter the total equity (net worth) amount reported on the corporate tax report filed with the Pennsylvania Department of Revenue.

Enter the bond issue identifier or name for the first listed corporate bond (for example series name, issue date, or other designation).

Enter the name (and, if space permits, the address) of the transfer or paying agent for the first listed bond issue.

Enter the total number of bonds of this issue that remain outstanding as of the report date.

Enter the total outstanding principal amount for this bond issue as of the report date.

Enter the name and brief identifying description of the second corporate bond issue (e.g., issue title, series or identifying details).

Enter the name and mailing address of the transfer or paying agent that handles the second bond issue.

Enter the total number of bonds from the second issue that remain outstanding as of this report.

Enter the total dollar amount still outstanding for the second bond issue as of this report.

Enter the name or identifying description of the corporate bond issue for the third listed entry.

Enter the name and address of the transfer or paying agent for this bond issue (third entry).

Enter the total number of bonds of this issue that remain outstanding as of this report for the third entry.

Enter the total monetary amount outstanding for this bond issue as of this report for the third entry.

Enter the full name of the first transfer or paying agent (individual or company) who is not listed elsewhere and who has handled corporate bond issues.

Enter the complete mailing address (street, city, state, and ZIP) for the first transfer or paying agent named in this entry.

Enter the full legal name of the other transfer or paying agent (company or individual) who handled corporate bond issues for this second entry.

Enter the full mailing address for that transfer or paying agent (street, city, state and ZIP) for this second entry.

Enter the full name of the third transfer or paying agent (company or individual) who handled corporate bond issues.

Enter the complete mailing address for that third transfer or paying agent, including street, city, state and ZIP code.

Check this box if you have consumed or used in Pennsylvania any tangible personal property or acquired such property on which no Pennsylvania sales or use tax was paid (after March 6, 1956).

Check this box if you have NOT consumed or used in Pennsylvania any tangible personal property or acquired such property on which no Pennsylvania sales or use tax was paid (after March 6, 1956).

Check this box if the business has within its custody, possession, or control any abandoned or unclaimed (escheatable) funds or assets (for example: dividends, payroll, deposits, outstanding checks, stock certificates, unidentified deposits, accounts payable debit balances, gift certificates, outstanding debentures or interest, royalties, mineral rights, or funds due missing shareholders).

Check this box if the business does not have any abandoned or unclaimed (escheatable) funds or assets in its custody, possession, or control.

Check this box if the business filed a Pennsylvania Abandoned and Unclaimed Property Report for the preceding year.

Check this box if the business did not file a Pennsylvania Abandoned and Unclaimed Property Report for the preceding year.

Check this box if the business has held title to any real estate at any time during the five years preceding the date of this application.

Check this box if the business has not held title to any real estate at any time during the five years preceding the date of this application.

Enter the business's registered Pennsylvania mailing address, including P.O. Box, street name and number, or R.D. number and box number.

Enter the city or town for the registered Pennsylvania address.

Enter the Pennsylvania county in which the registered address is located.

Enter the state for the registered address (use the two-letter abbreviation or full state name).

Enter the ZIP code for the registered Pennsylvania address (5-digit ZIP or ZIP+4 if applicable).

Enter the name of the transferee (EE) or transferor (OR) and indicate whether the entry is EE or OR. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the date the property transfer occurred. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Provide the property's location by local political subdivision and county (for example, street address or parcel description, municipality/township and county). Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the date the applicant acquired the property. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the original cost amount allocated to the land. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the original cost amount allocated to the building. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the county's assessed value for the property. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the actual consideration received for the transfer, including any encumbrance assumed. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the property's market value (actual monetary worth) at the time of transfer. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the amount of Pennsylvania realty stamps affixed to the transfer document. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Provide any explanations or additional details related to this transfer (attach a separate sheet if more space is needed). Fill only if 'Row 1 - Amount of PA Realty Stamps Affixed' is '0' (no realty transfer tax was paid).

Enter the name of the transferee (EE) or transferor (OR) for this property transfer and indicate whether the entry is EE or OR. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the date the property transfer occurred for this row. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the property location by local political subdivision and county (street/municipality and county) for this transfer. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the date the property was originally acquired for this row. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the original cost attributed to the land portion of the property for this transfer. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the original cost attributed to the building portion of the property for this transfer. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the county assessed value for the property reported in this row. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the actual consideration paid or received for this transfer, including any encumbrances assumed. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the actual monetary worth (market value) of the property at the time of transfer for this row. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the amount of Pennsylvania realty stamps affixed to the document for this transfer. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Provide any explanation or additional details related to this transfer (for example, reasons no realty transfer tax was paid or other pertinent notes). Fill only if 'Row 2 - Actual Monetary Worth (Market Value) at Transfer' is '0' (no realty transfer tax was paid).

Enter the full name of the transferee or transferor and indicate whether the entry is EE or OR. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the date on which the property transfer occurred. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Provide the property’s local political subdivision (municipality or township) and the county where the property is located. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the date the applicant originally acquired the property. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the original cost amount paid for the land portion of the property. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the original cost amount paid for the building or improvements on the property. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the county-assessed value for the property. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the total actual consideration paid for the property, including any encumbrances assumed. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the market value or actual monetary worth of the property at the time of the transfer. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the amount of Pennsylvania realty stamps affixed to the transfer document. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Provide any additional explanation, clarifying details, or notes about this transfer (attach additional sheet if more space is needed). Fill only if 'Row 3 - Actual Monetary Worth (Market Value) at Time of Transfer' is '0' (no realty transfer tax was paid).

Enter the full name of the transferee or transferor for this property and indicate whether they are EE or OR. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the date on which this property was transferred. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the property's address or legal description and specify the local political subdivision (township/borough/city) and county. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the date the property was originally acquired by the business or owner. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the original purchase cost of the land portion of the property in dollars. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the original purchase cost of the building portion of the property in dollars. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the property's county-assessed value. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the total consideration paid for the property, including any encumbrances assumed. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the property's market value at the time of transfer. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the amount paid for Pennsylvania realty stamps affixed to the transfer document. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Provide any explanation related to this transfer, such as details about partial interests, disposition agreements, or transfer tax notes. Fill only if 'Row 4 - Actual Monetary Worth (Market Value) at Time of Transfer' is '0' (no realty transfer tax was paid).

Enter the property location including the local political subdivision (municipality or township) and county for the Pennsylvania real estate being reported. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the date the property was acquired. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the original cost amount allocated to the land for this property. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the original cost amount allocated to the building for this property. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the county assessed value for the property. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the actual consideration paid for the property, including any encumbrances that were assumed. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the market value or actual monetary worth of the property at the time of transfer. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the amount (dollar value) of Pennsylvania realty stamps affixed to the transfer document. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Provide any required explanation or notes related to this property entry (e.g., if no realty transfer tax was paid, or other relevant details); if none, state 'None'. Fill only if 'Row 1 - Actual Monetary Worth (Market Value) at Time of Transfer' is '0' (no realty transfer tax was paid).

Enter the property's full local political subdivision and county (for example city, township or borough and county). Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the date on which this property was acquired. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the original purchase cost attributable to the land portion of the property. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the original purchase cost attributable to the building or improvements on the property. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the county-assessed value for the property. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the total consideration involved in the transfer, including any encumbrances assumed. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the property's market value at the time of transfer. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the amount of Pennsylvania realty stamps affixed to the transfer document, if applicable. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Provide any required explanation or notes about this property's transfer, disposition agreement, exemptions, or transfer-tax details. Fill only if 'Row 2 - Actual monetary worth (market value) at time of transfer' is '0' (no realty transfer tax was paid).

Enter the full property location in Pennsylvania, including the local political subdivision (municipality/township) and the county. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the date the property was acquired. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the original purchase cost attributable to the land portion of the property. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the original purchase cost attributable to the building or structures on the property. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the county-assessed value for the property as shown on local tax assessment records. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the total actual consideration paid for the property, including any encumbrances or liabilities that were assumed. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the market value of the property at the time of transfer. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the amount of Pennsylvania realty transfer stamps affixed to the document for this transaction. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Provide any explanatory notes related to this property entry (for example, disposition agreement references, partial interest details, or state 'None' if there is nothing to report). Fill only if 'Row 3 - Actual Monetary Worth (Market Value) at Time of Transfer' is '0' (no realty transfer tax was paid).

Enter the local political subdivision (township/borough/city) and county where the property is located. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the date the business acquired the property. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the original cost amount attributed to the land portion of the property. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the original cost amount attributed to the building portion of the property. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the county-assessed value for the property. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the actual consideration paid for the property, including any encumbrances assumed. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the property's estimated market value at the time of transfer. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Enter the amount of Pennsylvania realty stamps affixed to the document for this property. Fill only if 'Has the business held title to any real estate in the last five years from the date of this application?' is 'Yes'.

Provide any additional explanation or notes about the property or transaction, including reasons if no realty transfer tax was paid. Fill only if 'Row 4: Actual Monetary Worth (Market Value) at Time of Transfer' is '0' (no realty transfer tax was paid).

Enter the full legal name of the second responsible party (first and last name, and any suffix).

Enter the nine-digit Social Security Number of the second responsible party.

Enter the daytime telephone number for the second responsible party, including area code.

Enter the mailing address for the second responsible party (P.O. Box, street and number, or R.D. number and box number).

Enter the city or town for the second responsible party's mailing address.

Enter the state for the second responsible party's mailing address.

Enter the ZIP Code for the second responsible party's mailing address.

Enter the full name of the person who is authorizing the disclosure on behalf of the business.

Enter the job title or official position of the person signing the authorization.

Enter the date when the authorized person signed this statement.

Check this box if the business has been terminated and all Pennsylvania business operations have ceased as of the date of this application.

Check this box if the business has not been terminated and continues to conduct business activities in Pennsylvania.

If you answered Yes to terminating business activities in Pennsylvania, enter the date when the business distributed its assets. Fill only if 'Have you terminated your business activities in Pennsylvania? — Yes' is 'Yes'.

If you answered No to terminating business activities in Pennsylvania, provide a brief explanation describing why the business has not terminated its PA activities. Fill only if 'Have you terminated your business activities in Pennsylvania? — No' is 'Yes'.

Check this box if the business is a corporation and the assets or activities of the business will be transferred to another. Fill only if 'Type of Business' is 'DOMESTIC CORPORATION (Incorporated in PA)' or 'FOREIGN CORPORATION (not incorporated in PA)' or 'NONPROFIT CORPORATION'.

Check this box if the business is a corporation and the assets or activities of the business will not be transferred to another. Fill only if 'Type of Business' is 'DOMESTIC CORPORATION (Incorporated in PA)' or 'FOREIGN CORPORATION (not incorporated in PA)' or 'NONPROFIT CORPORATION'.

Check this box if the business is a partnership and the assets or activities of the business will be transferred to another. Fill only if 'Type of Business' is 'PARTNERSHIP'.

Check this box if the business is a partnership and the assets or activities of the business will not be transferred to another. Fill only if 'Type of Business' is 'PARTNERSHIP'.

Check this box if the business is a proprietorship and the assets or activities of the business will be transferred to another. Fill only if 'Type of Business' is 'PROPRIETORSHIP'.

Check this box if the business is a proprietorship and the assets or activities of the business will not be transferred to another. Fill only if 'Type of Business' is 'PROPRIETORSHIP'.

Check this box if the business is a liquidating trust and the assets or activities of the business will be transferred to another. Fill only if 'Type of Business' is 'LIQUIDATING TRUST'.

Check this box if the business is a liquidating trust and the assets or activities of the business will not be transferred to another. Fill only if 'Type of Business' is 'LIQUIDATING TRUST'.

Check this box if the business is an association and the assets or activities of the business will be transferred to another. Fill only if 'Type of Business' is 'ASSOCIATION'.

Check this box if the business is an association and the assets or activities of the business will not be transferred to another. Fill only if 'Type of Business' is 'ASSOCIATION'.

Check this box if the business type is 'Other' (describe in the Explain area) and the assets or activities of the business will be transferred to another. Fill only if 'Type of Business' is 'OTHER (Specify)'.

Check this box if the business type is 'Other' (describe in the Explain area) and the assets or activities of the business will not be transferred to another. Fill only if 'Type of Business' is 'OTHER (Specify)'.

Enter the full legal name of the person or business that will become the new owner. Fill only if 'A. Corporation — Yes', 'B. Partnership — Yes', 'C. Proprietorship — Yes', 'D. Liquidating Trust — Yes', 'E. Association — Yes', 'F. Other — Yes' is 'Yes' (any).

Enter the new owner's street mailing address, including apartment, suite, or P.O. Box details as applicable. Fill only if 'A. Corporation — Yes', 'B. Partnership — Yes', 'C. Proprietorship — Yes', 'D. Liquidating Trust — Yes', 'E. Association — Yes', 'F. Other — Yes' is 'Yes' (any).

Enter the city or town for the new owner's street address. Fill only if 'A. Corporation — Yes', 'B. Partnership — Yes', 'C. Proprietorship — Yes', 'D. Liquidating Trust — Yes', 'E. Association — Yes', 'F. Other — Yes' is 'Yes' (any).

Enter the state for the new owner's address (use the two‑letter abbreviation or full state name). Fill only if 'A. Corporation — Yes', 'B. Partnership — Yes', 'C. Proprietorship — Yes', 'D. Liquidating Trust — Yes', 'E. Association — Yes', 'F. Other — Yes' is 'Yes' (any).

Enter the postal ZIP code for the new owner's address (5‑digit or ZIP+4 as available). Fill only if 'A. Corporation — Yes', 'B. Partnership — Yes', 'C. Proprietorship — Yes', 'D. Liquidating Trust — Yes', 'E. Association — Yes', 'F. Other — Yes' is 'Yes' (any).

Enter a brief explanation describing the 'Other' manner in which the business assets or activities will be transferred, including relevant details such as parties involved and nature or reason for the transfer. Fill only if 'F. Other — Yes' is 'Yes'.

Check this box if the business is a domestic corporation incorporated in Pennsylvania.

Check this box if the business is organized as a partnership.

Check this box if the business is an association.

Check this box if the business is organized as a limited liability partnership (LLP).

Check this box if the business is a corporation incorporated outside Pennsylvania (a foreign corporation).

Check this box if the business is a proprietorship (sole proprietorship).

Check this box if the business is organized as a business trust.

Check this box if the business type is not listed and write the specific business type on the provided line.

If your business type is not listed among the checkboxes, enter the specific business type or classification here (e.g., "S-corporation", "Nonprofit Educational Trust", etc.). Fill only if 'Other (Specify)' is 'Yes'.

Check this box if the business is a nonprofit corporation and submit a copy of the 501(c) exemption letter when required.

Check this box if the entity is a liquidating trust.

Check this box if the business is a limited liability company (LLC).