REV-181 (CM) 02-21
       
                                                                                                                                                                                                                                                                                                 Department Use Only 
                                            
                                                                         APPLICATION FOR TAX 
                            Bureau of Compliance                      CLEARANCE CERTIFICATE                                                                    Revenue id                                                                                                                         
                            PO BOX 280947 
                            Harrisburg  PA 17128-0947                                                          NO FILING FEE                                                                                                                                                                     Please Type or Prin                                                                               t
Start
Ü      1     name of Business                                                                                                                                     eiFederaln                                                                                                                                                                                                        
                2           Locatio n of Busin ess (Curren t Mailing Address) 
                P.O. Box, Streetna d number ordR. . numbern                       a d Box number                                                            nTelepho e number 
                                                                                                                                                                                                City or Tow                                                                               n nCou ty                                                   (                State                             ) i  Z P Code
      
                3           name, Addressna d Phon   e number of Attorn  ey or Represen                           tative to whom Clearan                  ce Certificate shouldn                                                                                                                                                                                                be se t (ifndiffere t from #2) 
                                                                                                                                                                                               name                                                                                                                                                         (                 n Telepho) e number 
                            P.O. Box, Streetna d number ordR. . numbern           a d Box number                                                                                                     
                City or Tow                                                                               n       n                      Cou ty                                                    State                             i                                                                                                                                                                        Z P Code

                4 name(s), Home Address(es)na d Social Security number(s) of Sole Proprietor,n                                                           Ge eraln Part ers,n                                                                                                                     Busi ess Trustee,nPresiden                                                                            t a d Treasurer of 
                the Corporatio n           or Chief e  xecutive Officer or MajoritynOw erenoftity. (Attach listin                                     g if necessary.) 
                name                                                                                                   Social Security number                n                                                                                                                                                                                                 Telepho e number 
                                                                                                                                                                                    (                 ) 
                P.O. Box, Streetna d number ordR. . numbern                       a d Box number     City                                                 State                             i                                                                                                                                                                                                          Z P Code 
                name                                                                                                   Social Security number                n                                                                                                                                                                                                 Telepho e number 
                                                                                                                                                                                    (                 ) 
                P.O. Box, Streetna d number ordR. . numbern                       a d Box number     City                                                 State                             i                                                                                                                                                                                                          Z P Code

                5 Type of Business 
                            dOMeSTiC CORPORATi Onin(         corporatedni  PA)                            FOReiGn CORPORATi                     Onn( otni corporatedni  PA)                                                                                                                                                                                                      nOnPROFiT CORPORATi              On 
                                                                                                                                                                                                                                                                                                                                                                                 (Please submit copy of 501(c) 
                            PARTneRSHiP                                                                   PROPRieTORSHiP                                                                                                                                                                                                                                                         exemptio nletter)
                            ASSOCiATiOn                                                                   BuSineSS TRuST                                                                                                                                                                                                                                                         Liquid  ATinG TRuST
                            LiMi edT  i L ABiLi yT  PARTneRSHiP                                           OTHeR (Specify)                                                                                                                                                                                                                                                        LiMi edTi L ABiLi yT  COMPAny 
                 if d       omestic Corporation, giveni corporatio n  date.   if Foreig n                      Corporation                   , give state wheren  i corporatedn                                                                                                                                                                       a d date of Certificate of Authorityn                            i  PA.
                                                                                                                              MM/DD/YYYY                                                                                                                                                                                                              MM/DD/YYYY
                Registered Pennsylvania Address, P.O. Box, Streetn                         a d number 
      
                City or Tow                                                                               n       n                      Cou ty                                                    State                             i                                                                                                                                                                        Z P Code 
                 date business startedni  Pennsylvania                                              d                                    ate terminated 
                                                                                                                                                                                          MM/DD/YYYY                                                                                             MM/DD/YYYY 
                 6 describe the busin ess activityni  Pennsylvania, including services performedna d ren                                              dered,na d give prin                                                                                                                       cipal commodity sold at wholesale or 
        retail. if sales or con                 structio n areni volved, please explain i                      .  f man                  ufacturer’s represen tativesnor i depen                                                                                                                 ndent co tractors perform activities, 
        render services or execute salesno  behalf of then e tity ratherntha n                                                           e tity’s employees, please specify what activities were performed, what 
        services were ren                      deredna d what type of sales were executed. 

                 7 did the entity have employees for which PA person                                     nal i come tax wasq                 re uired to be withheld from wages?  
                  
                 8 did taxpayer ever holdna y of the followin         g licen              ses, permits or accoun                            ts with the Common     wealth ofMM/DD/YYYYPA? 
                (a)   Corporatio n             Tax                                       y es     no      Period                                       to                              Reven                                                                                                                                                                                       ueid no. 
                (b)   Malt Beverage orqLi uor Licen              se             y es     no      Period                                        to                                     Licen                                                                                                                                                                                       se no. 
                (c)   Liquid Fuels                                              y          es     no      Period                                        to                            Permit  no. 
                (d)   Cigarette Tax                                           y            es     no      Period                                       to                              Licen                                                                                                                                                                                      se no. 
                (e)   Sales, u           sena d Hotel Occ. Tax                y   es     no      Period                                        to                                     Licen                                                                                                                                                                                       se no. 
                (f)   Motor Carrier                                            y           es     no      Period                                       to                              Licen                                                                                                                                                                                      se no. 
                (g)   Fuel d ealer-user                                      y    es     no      Period                                        to                                     Licen                                                                                                                                                                                       se no. 
                (h)   Lottery                                                      y       es     no      Period                                        to                            Agen                                                                                                                                                                                        t    no. 
                (i)    Small Games of Chan             ce Mfg.d/  istr.     y     es     no      Period                                                                 to                                                                                                                                                                                                      nLice se no. 
                (j)    Public Tran         sportatio n Assistan    ce           y es     no      Period                                        to                                     Licen                                                                                                                                                                                       se no. 
                (k)   PAunemployment Compensatio            n            yes     no      Period                                        to                                             Accoun                                                                                                                                                                                        tno. 
                (l)    PA Oil Compan            y Fran chise Tax               y  es     no      Period                                                               to                                                                                                                                                                                                        Accoun tno. 

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9  Were the assets or activities of the business acquired in whole or in part from a prior business entity?
   Yes             No   ( If “Yes”, give predecessor’s name, address and acquisition date. )
   Name                                                                                       Acquisition Date  
                                                                                              MM/DD/YYYY
   P.O. Box, Street and Number
   City or Town                                                                               County                                               State                          ZIP Code
10 Has the business held title to any real estate in the last five years from the date of this application?                                                               Yes   No
   lIf “Yes”, complete Schedule A (last page).
   lIf you currently hold title to real estate in PA, complete Schedule B (last page).
11 Will the assets or activities of the business be transferred to another?If “Yes”, complete:
                                                                                              Name of New Owner
   A.       Corporation                                Yes                    No              F. Other  Yes       No
   B.       PartnershipYes                          No             Explain:                   Street Address of New Owner
   C.       ProprietorshipYes                       No
   D.       Liquidating Trust                          Yes         City StateNoZIP Code
   E.       AssociationYes                          No
12 Purpose of Clearance Certificate (check appropriate block):
   A. Dissolution of Corporation or Association through Department of State.
   B. Dissolution of Corporation or Association through Court of Common Pleas. Date Court was petitioned and county:

                        (date)MM/DD/YYYY                                             (county)
   C. Withdrawal of Foreign Corporation through Department of State
   D. Merger or consolidation of two or more Corporations or Associations where surviving Corporation or Association is not subject to the
        jurisdiction of Pennsylvania. (See 15 Pa C.S. § 139.)
   E.   Bulk Sale Clearance Certificate under Section 1403 of the Fiscal Code. Sale date:     MM/DD/YYYY
        Copy of settlement statement:
        Corporation Tax PurposesEmployer Withholding Tax PurposesSales, Use and Hotel Occupancy Tax Purposes
        Unemployment Compensation Tax Purposes
                                                 STATEMENT OF AUTHORIZATION
   I authorize the PA Department of Revenue to disclose, verbally or in written form, all tax filings, payments or delinquencies
   requested by the buyer or his representatives for the bulk sale transfer provision.                  MM/DD/YYYY

   Authorized by                                                                              Title                                            Date
   F.   Foreign Corporation Clearance Certificate under the provisions of the Act of 1947, P.L. 493, Contract Number and Political Subdivision:

13 Location of business records, available for audit of Pennsylvania operations.
   P.O. Box, Street and Number                                                                                    City                                                    State   ZIP Code

   Telephone Number
14 List any matters pending with the PA Department of Revenue (e.g. petitions, appeals):

15 Did the business ever, within the Commonwealth of PA:                                                MM/DD/YYYY
   (a)      Engage in the sale of soft drinks or soft drink syrup ........................................................                                        Yes No  Period          to
   (b)      Own or lease and operate diesel-powered motor vehicles on PA highways?....................                                                            Yes No  Period          to
   (c)      Engage in the sale of diesel fuel to motor vehicles using PA highways? ..........................                                                     Yes No  Period          to
   (d)      Engage in the sale or lease of tangible personal property since Sept. 1, 1953?                                                         .............. Yes No  Period          to
   (e)      File PA Unemployment Compensation Reports?................................................................                                            Yes No  Period          to
        If “Yes”, give Account Number                              (See question 8k.)
16 Have you terminated your business activities in Pennsylvania?
   Yes            No
   lIf “Yes”, give distribution of assets date:        MM/DD/YYYY
   lIf “No”, explain:
   lIf a Foreign Corporation, have you terminated business in the state of your incorporation?                                                                        Yes No

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17          number of employeesna d total gross payrollsnduri g the last five operatin                             g years (as reported to the Social Securityn   Admin   istratio ): 
                   yeAR                     TOTAL e MPLOyeeS                               PA              TOTAL GROSS                     PA 
                                                                        MPLOe                yeeS             PAyROLL               GROSS PAy      ROLL 

18         Have the officers receivedna y remun       eration n, i  cash or other other form, for services performedn                   nni sylvaPenia during the current calendar 
           year or during any of the precedin       g four calendar years? 
               yes     no 
19         Were any remunerated services performed for the busin                           essn i  PA, which you believendid not co stitute “employmen        t”nas defi ed 
           i nthe PAunemployment Compensatio n           Law?    yes     no 
            if “yes”, explain: 

20          A.  Average number of stockholders durin          g the last five years:
            B.  number of stockholders as of this report:
            C.  List names and home addresses of stock tran                           sfer agen ts who havenha dled the corporation   ’s stock:
                name:                                                                                      Address:

            d.  Were all shares presen      tedna d property redeemed fromn                        a y stock called for redemptio n or retired?  yes     no  
21          The figures below must agree with the last corporate tax report filed withdthe PA  epartmen                               tnof Reve ue. 
            date of Report:                 MM/DD/YYYY            Total Liabilities: 
           Total Assets:                                          Total equity (net worth): 
22          A. List the amount of corporate bon       ds issuedna d still outstan ndi g as of this report. Show each issue separatelyn                    na d include name a d
                address of any transfer or payin g agen    ts.
            ssuei                                              Agent                                                        number of Outstan ndi g Bonds                   Amount 

            B. List names and addresses of transfer or payin      g agen              ts not listed above who havenha dled corporaten         bo d issues.
            name:                                                             Address:

23         Have you consumed or usedni  Pennsylvania any tangible personal property or acq                           uired such, after March 6, 1956,n     o  which no PA sales or use 
            tax was paid? i fy“ es”, please explain   : 
               yes     no 
24          do you have withi n your custody, possessio n       ornco trolna y aban                don edna dnu claimed (escheatable)nfu ds or assets such as dividen        ds, 
         payroll, deposits, outstan ndi g checks, stock certificates,n                       unide tified deposits, accoun  ts payable debitn bala ces, gift certificates,n noutsta di g 
         debentures orni terest, royalties, min       eral rights ornfu ds due missin                  g shareholders or othern  u claimednamou ts payable? 
               yes     no 
25         Has the business filed a PA Aban    don    ednaund claimed Property Report for the precedin                      g year? 
               yes     no 
26         CeRTiFiCATiOn:   icertify that theni formatio n        providedn(i cludin                 g Schedules, if applicable)n   o  this applicatio n  hasnbee  examin   ed bynme a d 
            is, to the best of mynk owledge, truena d correct. (Certificatio n                       must agree withn  i dividuals listedn i  questio n  4.) 
                Print name                                                                   Original Signature      Signature of Officer – Please sign after printing
                Print name                                                                   Original Signature      Signature of Officer – Please sign after printing
         This form will serve asna  applicatio n      for clearan ces from both thedPA  epartmen                     t of Reven nue a ddPA  epartmen   t of Laborindustry.& 
        nOTe:        l Submit typed origin al to the PA department of Revenue (addressno  Page 1) and one copy to the PAdePARTMe                                  nT OF LABOR & 
                       indu STRy, OFFiC e   OF uneMPLOyMenT COMPenSATiOn TAX SeRvi eC S, e-GOveRnMenT uni T, LABOR & i dun                                  STR yBui diL nG, ROOM 
                       916, 651 BOAS ST.,  HARRi      SBu  RG PA 17121. Retai n                    a copy for taxpayer’s record. 
                    l  direct telephon enqi uiries to the PA d epartmen                    t of Reven  ue  at 717-783-6052 or at 717-346-2001. Services for taxpayer with special
                       hearing /speaking n  eeds ca n be accessed at 1-800-447-3020. Call thedPA  epartmen                            t of Laborindustry& at 866-403-6163, Optio n     2
                       or 717-783-3545 for services for the hearin                         g impaired.

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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 PENNSYLVANIA                                                                                                                                                                                                                                                                                                                                                  SCHEDULE A - STATEMENT OF ACQUISITION AND/OR DISPOSITION OF PENNSYLVANIA REAL ESTATE WITHIN FIVE YEARS FROM THE DATE OF THIS AP
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           NOW OWNED REAL ESTATE                     STATEMENT SCHEDULE B                                                                                                                                                                                  Indicate each by symbol                                                                                     Name of Transferee (EE) 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              OF ALL                                                                                                                                                                                                                                                           or Transferor (OR).
                                                                                                                                                                                                                                                                                                                                **                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    EE or OR.
                                                                                                                                                                                                                                                                                                                                                                                                                               *
                  including county, date of acquisition and nature of property (residential, industrial, acreage, commercial or farmland). If none, state none. If application is for a Bulk Sale Clearance Certificate, attach a list of PA properties that will be retained. For each property, provide the complete address,                                                                                                                                                                                                                                          If under agreement of disposition, attach copy of executed agreement for each property so affected.                                                                                                                                                List all real estate now owned in PA that the business will dispose of prior to or at the time of the action for which a clearance is required.
Reset Entire Form                                                                                                                                                                                                                                                                                                                                                                                                              Complete if applicable. If transfer represents less than a full fee-simple interest in the property, explain on a separate sheet of paper.
                                                                                                                                                                                                                                                                                                                                If no realty transfer tax was paid, explain on attached sheet or in “Explanation” column above.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   MM/DD/YYYY
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     Local Political Subdivision                                                                                                    Local Political Subdivision
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             Property Location by                                                                                                                 Property Location by
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    & County                                                                                                                                           & County

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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 Acquisition                                                                                                                   Acquisition
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             Date               Land                                                                                                       Date               Land  

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          MM/DD/YYYY                                                                                                                               MM/DD/YYYY

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             Original Cost                                                                                                                                                             Original Cost

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             Building                                                                                                                      Building 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               ation including                         Actual Consider-
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            Assumed                     Encumbrance                                                 ation including          Actual Consider-         Assumed                              Encumbrance

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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           Assessed Value       
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    at Time of Transfer                      Assessed Value                                                  Actual Monetary Worth                     at Time of Transfer                                                                        Actual Monetary Worth
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     (Market Value)                                                                                                                 (Market Value) 

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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            **                                                                                                                                      **

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     Stamps Affixed to                       Amount of PA Realty                                                                    Stamps Affixed to                             Amount of PA Realty
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             Explanation                                                                                                                   Explanation
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