IMPORTANT: FILL IN FORM MUST BE DOWNLOADED ONTO YOUR COMPUTER PRIOR TO COMPLETING

                                      (TR) MOD 12-22 
                                                                                              OFFICIAL USE ONLY
                     REV-1706
                                                                 BUSINESS/ACCOUNT 
                                                          CANCELLATION FORM

SECTION I                BUSINESS INFORMATION
Legal Name (For individual applicants give your full legal name)                                FEIN

Trade Name or DBA (if different from Legal Name)                                                SSN (sole proprietor’s if FEIN does not exist)

SECTION II               SALES TAX LICENSE CANCELLATION INFORMATION
Sales Tax License is non-transferable.
Sales Tax Account ID                                                  Reporting and Paying Under Another Account ID Number:
                                                                       Sales Tax Account ID:
                                                                                                          Cancellation Date
Business Discontinued

SECTION III              WITHHOLDING ACCOUNT CANCELLATION INFORMATION
Employer Withholding Tax Account ID                                   Reporting and Paying Under Another Account ID Number:
                                                                      Employer Withholding Tax Account ID:
Reason for Cancellation:          No Longer has Employee(s) Subject to PA Personal Income Tax             Cancellation Date
                                  Business Closed or Sold        Other
Other Income Withholding Account ID                                   Reporting and Paying Under Another Account ID Number:
                                                                      Account ID:
Reason for Cancellation:          No Longer Withholding PA Personal Income Tax                            Cancellation Date
                                  Business Closed or Sold        Other
Retirement Withholding Account ID                                     Reporting and Paying Under Another Account ID Number:
                                                                      Account ID:
Reason for Cancellation:          No Longer Withholding PA Personal Income Tax                            Cancellation Date
                                  Business Closed or Sold        Other
SECTION IV               PUBLIC TRANSPORTATION ASSISTANCE FUND TAXES AND FEES/VEHICLE RENTAL TAX INFORMATION
PTA License is non-transferable.
PTA Tax Account ID                                                    Business Discontinued Date

Reporting and Paying Under Another Account ID Number:
PTA Tax Account ID:                                       VRT Tax Account ID:
Vehicle Rental Tax Information:
VRT Account ID                                                        Business Discontinued Date

SECTION V                TOBACCO PRODUCTS LICENSE CANCELLATION INFORMATION
Tobacco Products License is non-transferable.
Tobacco Products License Number                                       Business Discontinued Date

SECTION VI               CONSUMER FIREWORKS TAX CANCELLATION INFORMATION
Consumer Fireworks Tax Account ID                                     Business Discontinued Date

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      IMPORTANT: FILL IN FORM MUST BE DOWNLOADED ONTO YOUR COMPUTER PRIOR TO COMPLETING

                  REV-1706 (TR) MOD 12-22

SECTION VII       WINE EXCISE TAX CANCELLATION INFORMATION
Wine Excise Tax Account ID                             Business Discontinued Date

SECTION VIII      AFFIRMATION
I hereby state under penalty for unsworn falsification to authorities (pursuant to 18 Pa.C.S. § 4904) that the undersigned has reviewed this document and 
the answers and information provided herein are true, correct and complete to the best of my knowledge, information and belief.
Name                                     Signature                               Date
                                                   PLEASE SIGN AFTER PRINTING
Title                                    Email Address                           Telephone Number

                                         PAGE 2
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                                                                 Instructions for REV-1706 
REV-1706 IN (TR) MOD 12-22                                                 Business/Account Cancellation Form

This form must be completed if the business was 
discontinued, sold or ceased operations in Pennsylvania.                          SECTION IV                             
For immediate updates, users may make changes                 PUBLIC TRANSPORTATION ASSISTANCE FUND TAXES 
directly to their accounts at mypath.pa.gov. This form        AND FEES/VEHICLE RENTAL TAX INFORMATION 
should be used for state/local sales/use tax, employer        If the business no longer has sales, rentals or leases subject 
withholding tax, Public Transportation Assistance Fund taxes  to PTA/VRT taxes and fees, or the sales tax license was 
and fees, vehicle rental tax,  Tobacco Product license,       cancelled, indicate business-discontinued date on the form. 
                                                              If the business reports under another Account ID Number, 
consumer fireworks tax and wine excise tax. When using 
                                                              indicate the new Account ID Number on the form. 
this form for multiple taxes, the Account ID Numbers for the 
corresponding taxes must be entered.                                              SECTION V
                                                                                                                         
                                                              TOBACCO PRODUCTS LICENSE CANCELLATION 
              LINE INSTRUCTIONS                             
                                                              INFORMATION 
                                                              If cigarettes or other tobacco products are no longer sold or 
                    SECTION II                              
                                                              if the sales tax license was cancelled, complete this 
SALES TAX LICENSE CANCELLATION INFORMATION                    information and indicate the date the business ceased 
Complete this section to cancel a sales tax license when a    selling cigarettes and other tobacco products. 
business: 
     ●Was discontinued, sold or ceased operations in                              SECTION VI                             
      Pennsylvania;                                           CONSUMER FIREWORKS TAX CANCELLATION 
     ●No longer makes taxable sales, rentals or leases;       INFORMATION 
     ●No longer provides taxable services in Pennsylvania; or If fireworks are no longer being sold or if the sales tax license 
                                                              was cancelled, complete this information and indicate the 
     ●Reports and pays under another Account ID Number. 
                                                              date the business ceased selling fireworks. 

                    SECTION III
                                                                                  SECTION VII                            
EMPLOYER WITHHOLDING TAX CANCELLATION                         WINE EXCISE TAX CANCELLATION INFORMATION 
INFORMATION                                                   If the business is no longer a direct wine shipper licensed in 
If the business was sold, closed or no longer has             Pennsylvania and is no longer responsible to collect and 
employee(s) subject to PA personal income tax, complete       pay wine excise tax, or the sales tax retail license was can-
this section. Provide the reason for the cancellation and the celled, complete this information and indicate the business-
required cancellation dates on this form.                     discontinued date on the form. 

OTHER INCOME WITHHOLDING                                                          SECTION VIII
                                                                                                                         
If the business was sold, closed or no longer withholding on 
                                                              AFFIRMATION 
non-wage sources and issues forms 1099-MISC or 
                                                              Sign and date the form. Include a daytime telephone 
1099-NEC, complete this information and indicate the final 
                                                              number, title and email.  
cancellation date. 
                                                              Fax or Email the completed form to: 
RETIREMENT WITHHOLDING 
                                                                 Fax: 717-787-3708 
If the business was sold, closed or no longer withholding tax    Email: RA-BTFTREGISFAX@PA.GOV 
on retirement income and issues forms 1099-R, complete 
this information and indicate the final cancellation date.                 REGISTRATION METHOD
                                                                                                                         
If the EIN is changed by the Internal Revenue Service, a      To register, complete the Pennsylvania Online Business Tax 
new registration must be completed.                           Registration at mypath.pa.gov.

www.revenue.pa.gov                                                                                        REV-1706      1

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