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

                                      (TR) 03-21 (FI)
                      REV-1605 
                      BUREAU OF REGISTRATION         NAMES OF CORPORATE 
                      AND TAXPAYER MANAGEMENT
                                                            OFFICERS

START SECTION I        BUSINESS INFORMATION
HERE  Business Name                                                                                 EIN
Ü
      Revenue ID                                             Department of State Entity Number

      Street Address                                         City                                   State     ZIP Code

      SECTION II       NAMES OF CORPORATE OFFICERS

      CORPORATE OFFICERS              SSN                   LAST NAME                              FIRST NAME         MI
      President/Managing Partner

            Vice President

            Secretary

      Treasurer/Tax Manager

      SECTION III      AFFIRMATION
     By filing this form, the taxpayer consents to the release of the names of its corporate officers and its address to the Department of State where it will be 
     available as a public record. I hereby affirm, under penalties prescribed by law, that information contained in this form is true and correct to the best of my 
     knowledge and belief, and that I am authorized to execute this form on behalf of the taxpayer.
      Preparer’s Name                                        Preparer’s Signature                   Date
                                                            PLEASE SIGN AFTER PRINTING
      Title                                           Email                                         Telephone Number

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                                                              Instructions for REV-1605 
REV-1605 IN (TR) 03-21                                                    Names of Corporate Officers

                                                              IMPORTANT: The Department of State Entity Number 
             GENERAL INFORMATION                              must be provided in order for the updates to be made 
PURPOSE OF REV-1605                                           to the Department of State. 
Use the Names of Corporate Officers, REV-1605 to add or                                                                 
change corporate officer information to an existing corporate             SECTION II
tax account. 
                                                              NAMES OF CORPORATE OFFICERS 
The Department of Revenue is required to forward the 
names of corporate officers received with tax reports to the  Complete all fields for each corporate officer. 
PA Department of State for inclusion in the public records of                                                           
the corporation. This information is provided from the                    SECTION III
corporate officer section of the RCT-101, Corporate Net 
Income Tax Report. Corporations may also update this          AFFIRMATION 
information during the year by completing this form and       An officer or a representative of the corporation must 
submitting it to the Department of Revenue, which will        complete and sign the form. 
forward this information to the PA Department of State for 
inclusion in the public records of the corporation.                       HOW TO FILE
                                                                                                                        
NOTE: Corporations may update names of 
corporate officers electronically through e-Tides at          Submit the completed and signed form by fax or email to: 
www.etides.state.pa.us.                                       Fax: 717-787-3708 
                                                              Email: RA-BTFTREGISFAX@PA.GOV
             FORM INSTRUCTIONS                       
                                                     
                       SECTION I

BUSINESS INFORMATION 
Provide the business name, federal entity identification 
number (EIN), revenue ID, Department of State entity 
number and business address. 

www.revenue.pa.gov                                                                         REV-1605                1
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