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TAXES AND SERVICES

REQUIREMENTS

SECTIONS TO

COMPLETE

l

CigAReTTe DeAleR’s

l

seCTion 19

CIGARETTE TAX is An exCise TAx imPoseD on The sAle oR Possession of

liCense

CigAReTTes. A DeAleR is Any CigAReTTe sTAmPing AgenT, wholesAleR,

oR ReTAileR.

l

sAles TAx liCense

l

seCTion 18

(ReTAileR)

CORPORATE NET INCOMEAND CAPITAL STOCK FRANCHISE TAXESARe imPoseD

l

RegisTRATion wiTh

PA DePARTmenT of sTATe

on DomesTiC AnD foReign CoRPoRATions, CeRTAin business TRusTs, AnD

l

seCTion 11

limiTeD liAbiliTy ComPAnies whiCh ARe RegisTeReD AnD/oR TRAnsACTing

l

foRms musT be obTAineD

business wiThin The CommonweAlTh of PennsylvAniA. subJeCTiviTy To

fRom PA DePARTmenT of

sTATe

sPeCifiC CoRPoRATion TAxes is DeTeRmineD by The TyPe of CoRPoRATe

oRgAniZATion AnD The ACTiviTy ConDuCTeD.

l FINANCIAL INSTITUTIONS TAXES: The bAnK AnD TRusT ComPAny shARes

TAx is imPoseD on eveRy bAnK AnD TRusT ComPAny hAving CAPiTAl

sToCK AnD ConDuCTing business in PennsylvAniA. DomesTiC TiTle

l

RegisTRATion wiTh feDeR-

insuRAnCe ComPAnies ARe subJeCT To The TiTle insuRAnCe ComPAny

Al oR sTATe AuThoRiTy

shARes TAx. The muTuAl ThRifT insTiTuTions TAx is imPoseD on sAv-

ThAT gRAnTeD ChARTeR

ings insTiTuTions, sAvings bAnKs, sAvings AnD loAn AssoCiATions,

AnD builDing AnD loAn AssoCiATions ConDuCTing business in Penn-

sylvAniA. CReDiT unions ARe noT subJeCT To TAx.

l GROSS PREMIUMS TAX is levieD on DomesTiC AnD foReign insuRAnCe

l

RegisTRATion wiTh

ComPAnies. The yeARly gRoss PRemiums ReCeiveD foRm The TAx

PA DePARTmenT of

bAse. gRoss PRemiums ARe PRemiums, PRemium DePosiTs, oR

insuRAnCe

AssessmenTs, foR business TRAnsACTeD in PennsylvAniA.

l GROSS RECEIPTS TAX is levieD on PiPeline, ConDuiT, wATeR nAvigATion

AnD TRAnsPoRTATion ComPAnies; TelePhone, TelegRAPh AnD mobile

l

RegisTRATion wiTh PA

TeleCommuniCATions ComPAnies; eleCTRiC lighT, wATeR PoweR AnD

PubliC uTiliTy

hyDRoeleCTRiC ComPAnies; AnD fReighT AnD oil TRAnsPoRTATion

Commission

ComPAnies.

The TAx is bAseD on gRoss ReCeiPTs fRom PAssengeRs, bAggAge

AnD fReighT TRAnsPoRTeD wiThin PennsylvAniA; TelegRAPh AnD

TelePhone messAges TRAnsmiTTeD wiThin PennsylvAniA; AnD sAles

of eleCTRiCiTy in PennsylvAniA.

l PUBLIC UTILITY REALTY TAX is levieD AgAinsT CeRTAin enTiTies fuR-

nishing uTiliTy seRviCes. PennsylvAniA imPoses This TAx on PubliC

l

RegisTRATion wiTh PA

uTiliTy ReAlTy in lieu of loCAl ReAl esTATe TAxes AnD DisTRibuTes

PubliC uTiliTy Commission

The loCAl ReAlTy TAx eQuivAlenT To loCAl TAxing AuThoRiTies.

l OTHER CORPORATION TAXES: This gRouP is ComPoseD PRimARily of

l

RegisTRATion wiTh PA

The CoRPoRATe loAns TAx, The CooPeRATive AgRiCulTuRAl AssoCiA-

DePARTmenT of sTATe

Tion AnD eleCTRiC CooPeRATive CoRPoRATion TAxes.

EMPLOYER WITHHOLDING is The wiThholDing of PennsylvAniA PeRsonAl

inCome TAx by emPloyeRs fRom ComPensATion PAiD To PennsylvAniA

l

seCTion 9

ResiDenT emPloyees foR woRK PeRfoRmeD insiDe oR ouTsiDe of Penn-

sylvAniA AnD nonResiDenT emPloyees foR woRK PeRfoRmeD insiDe

PennsylvAniA. (see unemPloymenT ComPensATion DefiniTion)

LIQUID FUELS AND FUELS TAX is An exCise TAx imPoseD on All liQuiD fuels

AnD fuels useD oR solD AnD DeliveReD by DisTRibuToRs wiThin Penn-

sylvAniA, exCePT Those DeliveReD To exemPT PuRChAseRs. liQuiD fuels

l

liQuiD fuels AnD fuels

l

seCTion 21

inCluDe gAsoline, gAsohol, JeT fuel, AnD AviATion gAsoline. fuels

TAx PeRmiT

inCluDe CleAR Diesel fuel AnD KeRosene. ADDiTionAlly, The liQuiD

fuels AnD fuels TAx ACT TAxes AlTeRnATive fuels (i.e. highwAy fuels

oTheR ThAn liQuiD fuels oR fuels) AT A ReTAil/use TAx level.

MOTOR CARRIERS ROAD TAX is imPoseD on moToR CARRieRs engAgeD in

oPeRATions on PennsylvAniA highwAys. A moToR CARRieR is Any PeRson

l

ifTA liCense AnD

oR enTeRPRise oPeRATing A QuAlifieD moToR vehiCle useD, DesigneD,

ifTA DeCAls

oR mAinTAineD foR The TRAnsPoRTATion of PeRsons oR PRoPeRTy

wheRe (A) The PoweR uniT hAs Two Axles AnD A gRoss oR RegisTeReD

l

PA non-ifTA vehiCle

l

seCTion 21

gRoss weighT gReATeR ThAn 26,000 PounDs, (b) The PoweR uniT hAs

RegisTRATion AnD PA non-

ThRee Axles oR moRe RegARDless of weighT, oR (C) vehiCles ARe useD

ifTA DeCAls

in CombinATion AnD The DeClAReD CombinATion weighT exCeeDs 26,000

PounDs oR The gRoss weighT of The vehiCles exCeeDs 26,000 PounDs.

PROMOTER is Any enTeRPRise engAgeD in RenTing, leAsing, oR gRAnTing PeR-

mission To Any PeRson To use sPACe AT A show foR The DisPlAy oR foR The

l

PRomoTeR liCense

l

seCTion 18

sAle of TAngible PeRsonAl PRoPeRTy oR seRviCes.

PUBLIC TRANSPORTATION ASSISTANCE FUND TAX is A TAx oR fee imPoseD on eACh

l

sAles use AnD hoTel

sAle in PennsylvAniA of new TiRes foR highwAy use, on The leAse of moToR

oCCuPAnCy TAx liCense

vehiCles, AnD on The RenTAl of moToR vehiCles. The TAx is Also levieD on The

l

seCTion 18

PubliC TRAnsPoRTATion

sTATe TAxAble vAlue of uTiliTy ReAlTy of enTeRPRises subJeCT To The PubliC

l

uTiliTy ReAlTy TAx AnD on PeTRoleum Revenue of oil ComPAnies.

AssisTAnCe TAx liCense

REPORTING AND PAYMENT METHODS offeR The enTeRPRise The AbiliTy To file

CeRTAin TAx ReTuRns AnD mAKe eleCTRoniC PAymenTs ThRough The eleCTRon-

iC TAx infoRmATion AnD DATA exChAnge sysTem (e-TiDes) oR The Telefile

sysTem. eleCTRoniC PAymenT mAy Also be mADe ThRough eleCTRoniC funDs

l

AuThoRiZATion

l

seCTion 12

TRAnsfeR (efT) oR CReDiT CARD. unemPloymenT ComPensATion (uC) wAges mAy

AgReemenT

be RePoRTeD viA A mAgneTiC meDium. in CeRTAin insTAnCes, An enTeRPRise mAy

eleCT To finAnCe uC CosTs unDeR A ReimbuRsemenT meThoD RATheR ThAn The

ConTRibuToRy meThoD.

SALES TAX isAn exCise TAx imPoseD on The ReTAil sAle oR leAse of TAxAble, TAn-

l

sAles use AnD hoTel

l

seCTion 18

gible PeRsonAl PRoPeRTy, AnD on sPeCifieD seRviCes.

oCCuPAnCy TAx liCense

l HOTEL OCCUPANCY TAX is An exCise TAx imPoseD on eveRy hoTel oR moTel

l

sAles use AnD hoTel

seCTion 18

Room oCCuPAnCy less ThAn 30 ConseCuTive DAys.

oCCuPAnCy TAx liCense

l

l LOCALSALES TAX mAy be imPoseD in PhilADelPhiAoRAllegheny CounTies, in

l

sAles use AnD hoTel

ADDiTion To The sTATe sAles AnD use TAx, on The ReTAil sAle oR use of TAn-

gible PeRsonAl PRoPeRTy AnD seRviCes AnD on hoTel/moTel oCCuPAnCies.

oCCuPAnCy TAx liCense

l

seCTion 18

SALES TAX EXEMPT STATUS FOR CHARITABLEAND RELIGIOUS ORGANIZATIONS is The

QuAlifiCATion of An insTiTuTion of PuRely PubliC ChARiTy To be exemPT fRom

l

CeRTifiCATe of exemPT

l

seCTion 22

sAles AnD use TAx on The PuRChAse of TAngible PeRsonAl PRoPeRTy oR seR-

sAles TAx sTATus

viCes foR use in ChARiTAble ACTiviTy.

l smAll gAmes of ChAnCe

SMALL GAMES OF CHANCE is The RegulATion of limiTeD gAmes of ChAnCe ThAT

DisTRibuToR liCense

QuAlifieD ChARiTAble AnD non-PRofiT oRgAniZATions CAn oPeRATe in Penn-

AnD/oR

l

seCTion 20

sylvAniA.

l

mAnufACTuReR

RegisTRATion CeRTifiCATe

TRANSIENT VENDOR is Any enTeRPRise whose business sTRuCTuRe is sole PRo-

PRieToR oR PARTneRshiP, noT hAving A PeRmAnenT PhysiCAl business loCATion

l

TRAnsienT venDoR

l

seCTion 18

in PennsylvAniA, whiCh sells TAxAble, TAngible PeRsonAl PRoPeRTy oR PeR-

CeRTifiCATe

foRms TAxAble seRviCes in PennsylvAniA.

UNEMPLOYMENT COMPENSATION (UC) PRoviDes A funD fRom whiCh ComPensATion

is PAiD To woRKeRs who hAve beCome unemPloyeD ThRough no fAulT of TheiR

own. ConTRibuTionsARe ReQuiReD To be mADe byAll emPloyeRs who PAy wAges

l

seCTions 7, 9,

To inDiviDuAls woRKing in PA AnD whose seRviCes ARe CoveReD unDeR The uC

l

APPliCATion foR

if APPliCAble

lAw. This TAx mAy inCluDe emPloyee ConTRibuTions wiThhelD by emPloyeRs

10 AnD 14

fRom eACh emPloyee’s gRoss wAges. (see emPloyeR wiThholDing DefiniTion)

exPeRienCe ReCoRD AnD

ReseRve ACCounT

l

seCTions 14,

l APPLICATION FOR PA UC EXPERIENCE RECORD AND RESERVE ACCOUNT BAL-

bAlAnCe of PReDeCessoR

15. if APPliC-

ANCE enAbles The RegisTeRing enTeRPRise To benefiT fRom A PReDeCes-

Able, 16

soR’s RePoRTing hisToRy. RefeR To The insTRuCTions To DeTeRmine if This

is ADvAnTAgeous.

USE TAX is An exCise TAx imPoseD on PRoPeRTy useD in PennsylvAniA on whiCh

l

use TAx ACCounT

l

seCTion 18

sAles TAx hAs noT been PAiD.

VEHICLE RENTAL TAX is imPoseD on RenTAl ConTRACTs by enTeRPRises hAving

l

sAles use AnD hoTel

AvAilAble foR RenTAl: (1) 5 oR moRe moToR vehiCles DesigneD To CARRy 15 oR

oCCuPAnCy TAx liCense

l

seCTion 18

less PAssengeRs, oR (2) TRuCKs, TRAileRs, oR semi-TRAileRs useD in The TRAns-

l

PTA liCense

PoRTATion of PRoPeRTy. A RenTAl ConTRACT is foR A PeRioD of 29 DAys oR less.

WHOLESALER CERTIFICATE PeRmiTs An enTeRPRise solely engAgeD in selling

TAngible PeRsonAl PRoPeRTy AnD/oR seRviCes foR ResAle. To PuRChAse TAngi-

l

wholesAleR CeRTifiCATe

l

seCTion 18

ble PeRsonAl PRoPeRTy oR seRviCes foR ResAle TAx-fRee when useD in The

noRmAl CouRse of The enTeRPRise’s business.

WORKERS’ COMPENSATION COVERAGE is MANDATORY AnD PRoTeCTs emPloyees

fRom wAge loss benefiTs AnD meDiCAl exPenses inCuRReD As A ResulT of Job

RelATeD inJuRies oR DiseAses. emPloyeRs ThAT mAinTAin woRKeRs’ ComPensA-

Tion CoveRAge ARe immune To lAwsuiTs flowing fRom woRK-RelATeD inJuRies

oTheR ThAn Those ACTions fileD unDeR The woRKeRs’ ComPensATion ACT.

eveRy emPloyeR liAble unDeR The PA woRKeRs’ ComPensATion ACT shAll

l

woRKeRs’ ComPensATion

l

seCTion 9

insuRe The PAymenT of ComPensATion wiTh The sTATe woRKmen’s insuRAnCe

CoveRAge

funD, oR wiTh Any PRivATe insuRAnCe ComPAny, oR muTuAl AssoCiATion oR

ComPAny, AuThoRiZeD To insuRe suCh liAbiliTy in This CommonweAlTh oR by

seCuRing The AuThoRiTy To self-insuRe. UNLESS ALL emPloyees ARe exCluDeD

fRom The CoveRAge ReQuiRemenTs, AnD fAll inTo one oR moRe of The exemPT

CATegoRies, woRKeRs’ ComPensATion musT be ConTinuAlly mAinTAineD wiTh

no inTeRRuPTion in CoveRAge.

4.

enTeRPRise legAl nAme

5.

feDeRAl emPloyeR iDenTifiCATion numbeR (ein)

6.

enTeRPRise TRADe nAme (if different than legal name)

7.

enTeRPRise TelePhone numbeR

(

)

8.

enTeRPRise sTReeT ADDRess (do not use PO Box)

CiTy/Town

CounTy

sTATe

ZiP CoDe + 4

9.

enTeRPRise mAiling ADDRess (if different than street address)

CiTy/Town

sTATe

ZiP CoDe + 4

10.

loCATion of enTeRPRise ReCoRDs (street address)

CiTy/Town

sTATe

ZiP CoDe + 4

11.

esTAblishmenT nAme (doing business as)

12. numbeR of

13. PA sChool DisTRiCT

14. PA muniCiPAliTy

esTAblishmenTs *

PREVIOUS

ACCOUNT NUMBER

AuThoRiZeD signATuRe (ATTACh PoweR of ATToRney if APPliCAble)

DAyTime TelePhone numbeR

TiTle

(

)

TyPe oR PRinT nAme

e-mAilADDRess

DATe

TyPe oR PRinT PRePAReR’s nAme

TiTle

DAyTime TelePhone numbeR

e-mAilADDRess

DATe

(

)

PA-100 (TR) 03-18

DePARTmenT use only

enTeRPRise nAme

1.

o sole PRoPRieToRshiP (inDiviDuAl)

o geneRAl PARTneRshiP

o AssoCiATion

o limiTeD liAbiliTy ComPAny

o CoRPoRATion (sec. 11)

o limiTeD PARTneRshiP

o business TRusT

STATE WHERE CHARTERED

o goveRnmenT (sec. 13)

o limiTeD liAbiliTy PARTneRshiP

o esTATe

o ResTRiCTeD PRofessionAl ComPAny

o JoinT venTuRe PARTneRshiP

STATE WHERE CHARTERED

o PRofiT

o non-PRofiT

2.

is The enTeRPRise oRgAniZeD foR PRofiT oR non-PRofiT?

3.

o yes

o no

is The enTeRPRise exemPT fRom TAxATion unDeR inTeRnAl Revenue CoDe (iRC) seCTion 501(c)(3)? if yes,

PRoviDe A CoPy of The enTeRPRise's exemPTion AuThoRiZATion leTTeR fRom The inTeRnAl Revenue seRviCe.

1.

nAme

2. soCiAl seCuRiTy numbeR

3.

DATe of biRTh *

4.

feDeRAl ein

5.

o owneR

o offiCeR

6. TiTle

7. effeCTive DATe

8.

PeRCenTAge of

9.

effeCTive DATe of

o PARTneR

o shAReholDeR

of TiTle

owneRshiP

owneRshiP

o ResPonsible PARTy

%

10. home ADDRess (street)

CiTy/Town

CounTy

sTATe

ZiP CoDe + 4

11. This PeRson is ResPonsible To RemiT/mAinTAin:

o sAles TAx

o emPloyeR wiThholDing TAx

o moToR fuel TAxes

PA BUSINESS ACTIVITY

%

PRODUCTS OR SERVICES

%

ADDITIONAL

%

PRODUCTS OR SERVICES

manufacturing

mining, Quarrying, & oil/gas extraction

other services

Professional, scientific, & Technical services

Public Administration

Real estate

Retail Trade

sanitary service

social Assistance services

Transportation

utilities

warehousing

wholesale Trade

ToTAl

100%

___________________ % new

+

__________________ % RenovATive

=

100%

___________________ % ResiDenTiAl

+

__________________ % CommeRCiAl

=

100%

4. o yes o no

Does This enTeRPRise wAnT To beCome A PennsylvAniA loTTeRy ReTAileR?

PA-100 (TR) 03-18

DePARTmenT use only

enTeRPRise nAme

1.

o yes

o no

is This esTAblishmenT selling TAxAble PRoDuCTs oR offeRing TAxAble seRviCes To ConsumeRs fRom A loCATion

IN PENNSYLVANIA? if yes, ComPleTe seCTion 18.

2.

o yes

o no

is This esTAblishmenT selling CigAReTTes IN PENNSYLVANIA? if yes, ComPleTe seCTions 18 AnD 19.

CounTy

CounTy

CounTy

CounTy

CounTy

CounTy

ATTACH ADDITIONAL 8 1/2 X 11 SHEETS IF NECESSARY.

3.

o yes

o no

Does This esTAblishmenT PAy RemuneRATion foR seRviCes To PeRsons you Do noT ConsiDeR emPloyees?

if yes, exPlAin The seRviCes PeRfoRmeD

4.

o yes

o no

DoesThisesTAblishmenTRePoRTnon-ResiDenTwiThholDingonnon-emPloyeeComPensATion,businessinComeoRleAsePAymenTs?

PART 2

1.

o yes

o no

is This RegisTRATion A ResulT of A TAxAble DisTRibuTion fRom A benefiT TRusT, DefeRReD PAymenT, oR ReTiRemenT PlAn

foR PA ResiDenTs?

if yes, inDiCATe: a.

DATe benefiTs fiRsT PAID (mm/DD/yyyy)

b.

esTimATeD benefiTs PAiD PeR QuARTeR

$

.00

1.

o yes

o no

DiD The enTeRPRise ACQuiRe 51% oR moRe of ANY CLASS of The PA ASSETS of AnoTheR enTeRPRise? see The ClAss of AsseTs

lisTeD below.

2.

o yes

o no

DiD The enTeRPRise ACQuiRe 51% oR moRe of The TOTALASSETS of AnoTheR enTeRPRise?

if The AnsweR To eiTheR QuesTion is yes, PRoviDe The following infoRmATion AbouT The SELLER/TRANSFEROR.

3.

selleR/TRAnsfeRoR nAme

4. feDeRAl ein

PA-100 (TR) 03-18

DePARTmenT use only

enTeRPRise nAme

5. o yes

o no

is This CoRPoRATion's sToCK PubliCly TRADeD?

CoRPoRATion: o sToCK

o PRofessionAl

bAnK: o sTATe

muTuAl ThRifT: o sTATe

insuRAnCe

o PA

o non-sToCK

o CooPeRATive

o feDeRAl

o feDeRAl

ComPAny:

o non-PA

o mAnAgemenT

o sTATuToRy Close

7. s CoRPoRATion: o feDeRAl

inACCoRDAnCe wiThACTno.67 of 2006, A CoRPoRATion wiTh feDeRAl sub-ChAPTeR s sTATus is ConsiDeReD A PA s CoR-

PoRATion. in oRDeR NOT To be TAxeD As A PA s CoRPoRATion, Rev-976 MUST be fileD. The foRm CAn be ACCesseD AT

WWW.REVENUE.STATE.PA.US, foRms AnD PubliCATions, CoRPoRATion TAx.

1.

is The enTeRPRise A:

o goveRnmenT boDy

o goveRnmenT owneD enTeRPRise

o goveRnmenT & PRivATe seCToR

owneD enTeRPRise

2.

is The goveRnmenT:

o DomesTiC/usA

o foReign/non-usA

o mulTi-nATionAl

3.

if DomesTiC, is The goveRnmenT:

o feDeRAl

loCAl: o CounTy

o boRough

o sTATe goveRnoR's JuRisDiCTion

o CiTy

o sChool DisTRiCT

o sTATe non-goveRnoR's JuRisDiCTion

o Town

o oTheR

o TownshiP

PA-100 (TR) 03-18

DePARTmenT use only

enTeRPRise nAme

1. PReDeCessoR legAl nAme

2. PReDeCessoR PA uC ACCounT numbeR

6.

sPeCify how The business wAs ACQuiReD:

o PuRChAse

o ChAnge in legAl sTRuCTuRe

o ConsoliDATion

o gifT

o meRgeR

o iRC seC. 338 eleCTion

o oTheR (sPeCify)

7.

o ACQuisiTion DATe

8.

PeRCenTAge of The PReDeCessoR's ToTAl business (PAAnD non-PA) ACQuiReD

%

9.

PeRCenTAge of The PReDeCessoR's PA business ACQuiReD

%

if less ThAn 100%, PRoviDe The nAme(s) AnD ADDRess(es) of The esTAblishmenT(s) ThAT ConDuCTeD oPeRATions in PA oR emPloyeD PA ResiDenTs.

ATTACh ADDiTionAl 8 1/2 x 11 sheeTs if neCessARy.

nAme of esTAblishmenT(s)

ADDRess(es)

11. AsseTs ACQuiReD:

o ACCounTs ReCeivAble

o eQuiPmenT

o leAses

o oTheR (sPeCify)

o ConTRACTs

o fixTuRes

o mAChineRy

o CusTomeRs/ClienTs

o fuRniTuRe

o nAme AnD/oR gooDwill

o emPloyees

o invenToRy

o ReAl esTATe

12.o yes

o no

hAs The PReDeCessoR CeAseD PAying wAges in PA? if yes, enTeR The DATe PA wAges CeAseD,

if Known.

13.o yes

o no

hAs The PReDeCessoR CeAseD oPeRATions in PA? if yes, enTeR The DATe PA oPeRATions CeAseD,

if Known.

if no, DesCRibe The PReDeCessoR's PResenT PA business ACTiviTy, if Known.

a. o yes

o no

weRe Any of The owneRs, shAReholDeRs (5% oR gReATeR), PARTneRs, offiCeRs, oR DiReCToRs of The PReDeCessoR

oR of Any AffiliATe, subsiDiARy oR PARenT CoRPoRATion of The PReDeCessoR Also owneRs, shAReholDeRs (5% oR

gReATeR), PARTneRs, offiCeRs, oR DiReCToRs of The RegisTeRing enTeRPRise oR of Any AffiliATe, subsiDiARy oR

PARenT CoRPoRATion of The RegisTeRing enTeRPRise?

b. o yes

o no

wAs The PReDeCessoR, oR Any AffiliATe, subsiDiARy oR PARenT CoRPoRATion of The PReDeCessoR, An owneR,

shAReholDeR (5% oR gReATeR), oR PARTneR in The RegisTeRing enTeRPRise?

c. o yes

o no

wAs The RegisTeRing enTeRPRise, oR Any AffiliATe, subsiDiARy oR PARenT CoRPoRATion of The RegisTeRing

enTeRPRise, An owneR, shAReholDeR (5% oR gReATeR), oR PARTneR in The PReDeCessoR?

PA-100 (TR) 03-18

DePARTmenT use only

enTeRPRise nAme

SECTION 15 – APPLICATION FOR PA UC EXPERIENCE RECORD

AND

RESERVE ACCOUNT

BALANCE OF PREDECESSOR

1. PReDeCessoR nAme

DATe

yeAR________

yeAR________

yeAR________

yeAR________

yeAR________

yeAR________

of TRAnsfeR

QuARTeRs

QuARTeRs

QuARTeRs

QuARTeRs

QuARTeRs

QuARTeRs

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

yeAR________

yeAR________

yeAR________

yeAR________

yeAR________

yeAR________

of TRAnsfeR

QuARTeRs

QuARTeRs

QuARTeRs

QuARTeRs

QuARTeRs

QuARTeRs

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

A.

ToTAl numbeR of emPloyees who eARneD TAxAble wAges in The PART OF THE BUSINESS OR WORKFORCE THAT WAS TRANSFERRED DuRing The PeRioD

fRom The fiRsT DAy of The QuARTeR of TRAnsfeR To The DATe of TRAnsfeR

.

b.

ToTAl numbeR of emPloyees who eARneD TAxAble wAges in The ENTIRE BUSINESS DuRing The PeRioD fRom The fiRsT DAy of The QuARTeR of

TRAnsfeR To The DATe of TRAnsfeR

.