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17 Number of employees and total gross payrolls during the last five operating years (as reported to the Social Security Administration):
YEAR TOTAL EMPLOYEESPA TOTAL GROSS PA
EMPLOYEES PAYROLLGROSS PAYROLL
18 Have the officers received any remuneration, in cash or other other form, for services performed in Pennsylvania during the current calendar
year or during any of the preceding four calendar years?
Yes No
19 Were any remunerated services performed for the business in PA, which you believe did not constitute “employment” as defined
in the PA Unemployment Compensation Law? Yes No
If “Yes”, explain:
20 A. Average number of stockholders during the last five years:
B. Number of stockholders as of this report:
C. List names and home addresses of stock transfer agents who have handled the corporation’s stock:
Name: Address:
D. Were all shares presented and property redeemed from any stock called for redemption or retired? Yes No
21 The figures below must agree with the last corporate tax report filed with the PA Department of Revenue.
Date of Report: MM/DD/YYYY Total Liabilities:
Total Assets: Total Equity (net worth):
22 A. List the amount of corporate bonds issued and still outstanding as of this report. Show each issue separately and include name and
address of any transfer or paying agents.
Issue Agent Number of Outstanding BondsAmount
B. List names and addresses of transfer or paying agents not listed above who have handled corporate bond issues.
Name: Address:
23 Have you consumed or used in Pennsylvania any tangible personal property or acquired such, after March 6, 1956, on which no PA sales or use
tax was paid? If “Yes”, please explain:
Yes No
24 Do you have within your custody, possession or control any abandoned and unclaimed (escheatable) funds or assets such as 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 or other unclaimed amounts payable?
Yes No
25 Has the business filed a PA Abandoned and Unclaimed Property Report for the preceding year?
Yes No
26 CERTIFICATION:I certify that the information provided (including Schedules, if applicable) on this application has been examined by me and
is, to the best of my knowledge, true and correct. (Certification must agree with individuals listed in Question 4.)
Print Name Signature of Officer – Please sign after printingOriginal Signature
Print Name Signature of Officer – Please sign after printingOriginal Signature
This form will serve as an application for clearances from both the PA Department of Revenue and PA Department of Labor & Industry.
NOTE:l Submit typed original to the PA Department of Revenue (address on Page 1) and one copy to the PA DEPARTMENT OF LABOR &
INDUSTRY, OFFICE OF UNEMPLOYMENT COMPENSATION TAX SERVICES, e-GOVERNMENT UNIT, LABOR & INDUSTRY BUILDING, ROOM
916, 651 BOAS ST., HARRISBURG PA 17121. Retain a copy for taxpayer’s record.
lDirect telephone inquiries to the PA Department of Revenue at 717-783-6052 or at 717-346-2001. Services for taxpayer with special
hearing /speaking needs can be accessed at 1-800-447-3020. Call the PA Department of Labor & Industry at 717-787-6637 or
717-783-3545 for services for the hearing impaired.
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