CITY OF PHILADELPHIA DEPARTMENT OF REVENUE

                                                      CHANGE FORM
         USE TO UPDATE ACCOUNT INFORMATION OR TO CANCEL A TAX LIABILITY
                                              MAIL THE COMPLETED CHANGE FORM TO:
CITY OF PHILADELPHIA, DEPARTMENT OF REVENUE, P.O. BOX 1410, PHILADELPHIA, PA, 19105-1410
                                                          OR FAX TO:  215-686-6635

         PHONE:  215-686-6600            E-MAIL:  revenue@phila.gov            INTERNET:  www.phila.gov/revenue

Businesses complete   Sections 1 and     to add a tax, request payment coupons or to close a business account.    2          For a change
of entity you must cancel your account and apply for a new Tax Account Number and Commercial Activity License                       .  Contact
the department to obtain an application or to register on-line visit our web site.  For property subject to Use and Occupancy
Tax complete   Section 3.  Individuals complete   Section 4 for School Income Tax or   Section 5 for Employee Earnings Tax.   
Section 6 must be completed for all requests including the signature of the preparer of this form.
Section 1 - Business Tax Registration Information.
  Currently Registered Business Name and Address                             Corrected Business Name and Address

City Account Number              Employer Identification Number                   City Account Number   Employer Identification Number
                                 -                                                                                      -
                Social Security Number                                                       Social Security Number

                       -         -                                                                    -                -
          Spouse's Social Security Number                                         Spouse's Social Security Number
                       -         -                                                                    -                -
Section  2  -  Add  a  tax,  request  payment     If your business has closed, enter the last day of business:
coupons or to cancel an account.                                                                                           - -
If your business never                                                    To add a new tax type, enter the start date:     - -
materialized, check here:
                                              ADD         CANCEL          COUPONS                                      ADD   CANCEL COUPONS

AMUSEMENT TAX                                                                     PARKING TAX
BEVERAGE TAX                                                                      TOBACCO TAX
BUSINESS INCOME & RECEIPTS TAX                                                    USE & OCCUPANCY TAX
HOTEL TAX                                                                         VALET PARKING TAX
NET PROFITS TAX                                                                   VEHICLE RENTAL TAX
OUTDOOR ADVERTISING TAX                                                           WAGE TAX

Section 3 - For property subject to Use and Occupancy Tax.
                                                                                          Business U&O Tax Account Number
Property Address
                                                                                                                           -
                                                                                             Property Account Number

                                                                                                      Cancellation Date
Use and Occupancy Tax Mailing Address  (If different from Property Address)
                                                                                                      -                -
                                                                                                      Date of Purchase

                                                                                                      -                -
Check Reason for Cancellation:
                Sold                          Residential                         Name of New Property Owner
                Vacant                        Other (Explain in Section 6)
                                                                                                                           83-E669 Rev. 2-7-2017

Section 4                                        SCHOOL INCOME TAX
If the preprinted information listed on your tax return is incorrect, use this form to make the necessary corrections.  For example, if your spouse
is deceased and you filed jointly with your spouse, use the Change Form to indicate your name and Social Security number.
  Currently Registered Taxpayer Name and Address              Corrected Taxpayer Name and Address

             Social Security Number                                           Corrected Social Security Number
             -              -                                                       -     -
             Spouse's Social Security Number                                  Corrected Spouse's Social Security Number
             -              -                                                       -     -
                                                                                                 Cancellation Date
Reason       Moved out of Philadelphia                      Spouse Filing Separately
for
Cancellation Deceased.  Enter date of death________________ No taxable Income              -                             -

Section 5                                        EMPLOYEE EARNINGS TAX
  Currently Registered Taxpayer Name and Address              Corrected Taxpayer Name and Address

             Social Security Number                                           Corrected Social Security Number

             -              -                                                       -     -

Reason       Moved out of Philadelphia           Employer now withholding tax             Cancellation Date
          for
Cancellation Deceased                            No longer employed                   -          -

Section 6                     State the reason for submitting this change form:

                            Contact information must be completed for all change requests.

             Form Completed By (print name):                                   Date

             Signature:                                                        Telephone #

             E-mail Address                                                    Fax #