CITY OF PHILADELPHIA                                  APPLICATION FOR
     DEPARTMENT OF REVENUE             EMPLOYEE EARNINGS (WAGE) TAX ACCOUNT

                 Your Social Security/ Individual Tax Identification Number is your Employee Earnings Tax Account Number.
                         Do not file this application if Philadelphia wage tax was withheld on all compensation.
APPLICANT'S NAME                                                     SOCIAL SECURITY/ INDIVIDUAL TAX IDENTIFICATION  NUMBER
                                                                                    --
HOME ADDRESS

CITY                                                                 STATE          ZIP CODE

DAYTIME TELEPHONE NUMBER    FAX NUMBER                               E-MAIL ADDRESS

EMPLOYER'S NAME                                                      EMPLOYER'S FEDERAL TAX IDENTIFICATION NUMBER
                                                                                   -
EMPLOYER'S ADDRESS

CITY                                                                 STATE          ZIP CODE

EMPLOYER'S TELEPHONE NUMBER FAX NUMBER                               E-MAIL ADDRESS

EMPLOYMENT START DATE       ARE YOU STILL EMPLOYED BY THIS EMPLOYER? IF NO, ENTER SEPARATION DATE
            --                         YES NO                                      --
     I HEREBY CERTIFY that the statements contained herein and in any supporting schedule or exhibit are true and correct to the best of my
     knowledge and belief.  I understand that if I knowingly make any false statements herein, I am subject to penalties as prescribed by law.
APPLICANT'S SIGNATURE                                                               DATE

                            MAIL COMPLETED APPLICATION TO:
                                       CITY OF PHILADELPHIA
                            DEPARTMENT OF REVENUE
                            1401 JOHN F. KENNEDY BOULEVARD
                            PHILADELPHIA, PA   19102
                            TO REGISTER ONLINE GO TO www.phila.gov/revenue
                            TELEPHONE:  215-686-6600     FAX:  215-686-6635

                                                                                                                83-T-104A Rev. 10-14-2014

      APPLICATION FOR EMPLOYEE EARNINGS (WAGE) TAX ACCOUNT

                         To apply online, go to www.phila.gov/revenue.

Note:  Under Act 48 of 1994, all employers having a place of business in Pennsylvania must withhold City Wage Tax
from Philadelphia Residents.

                                          WHO MUST FILE

Residents of Philadelphia who received compensation from which City wage tax was   not deducted on total wages.

Non-residents of Philadelphia who received compensation for services performed in Philadelphia and wage tax
was   not deducted on total wages.

                                        TAXABLE COMPENSATION

Gross Compensation includes wages, commissions, tips, bonuses, severence pay, sick and/or vacation pay, non-cash
compensation, and military reserve  pay not  including active duty.    Pension plan contributions (such  as  401k
contributions) are subject to wage tax and are not deductible from gross taxable compensation.

                                          TAX RETURNS

An annual reconciliation return, due April 15 following the calendar year, will  be  mailed to you.   You must include all
applicable W-2 forms with your return.  A coupon book containing prepayment coupons for each quarterly payment will be
mailed to you separately.  To make a current year quarterly payment go to www.phila.gov/revenue and click "Tax Returns"
then "Print Payment Coupon".  If you want a paper coupon mailed, contact Taxpayer Services at 215-686-6600.

                                        FILING FREQUENCY

                  Quarter                     Period Covered                  Due Date
                  1                     January, February, March              April 30
                  2                           April, May, June                July 31
                  3                     July, August, September        October 31
                  4                     October, November, December    January 31

                                        Interest and Penalty (General)

Effective January 1, 2014, the monthly interest rate is .416% and the penalty rate is 1.25% for all taxes except Liquor and
Real Estate.

For tax returns due on or before December 31, 2013 - Failure to pay by the due date will result in the imposition of interest
and penalty. The tax remaining unpaid after the due date is subject to interest at the rate of 1% per month or fraction of
each month until paid. The unpaid tax is also subject to penalty at rates that increase incrementally in accordance with the
following table:

                  Elapsed Time after Due Date                  Rate of Penalty

                  1st through 3rd month       1% per month or fraction thereof
                  4th through 6th month       2% per month or fraction thereof
                  7th through 9th month       3% per month or fraction thereof
                  10th through 12th month     4% per month or fraction thereof

Total penalty after 12 months is 30%. Thereafter, penalty is charged at the rate of 1 1/4% per month or fraction thereof.

Payments made after the due date that do not include applicable interest and penalty will be automatically pro-rated
between principal, interest and penalty.

                                                                                              83-T-104B Rev. 10-14-2014