(SU) 09-19 
                                    BUSINESS TRUST FUND           OFFICIAL USE ONLY
                        REV-563 
                                    TAXES RESPONSIBLE PARTY 
                                    INFORMATION FORM

      Use this form to report or update the person(s) who has active control or authority over a business or organization or direct control over finances for 
      business trust fund tax purposes.
      SECTION I BUSINESS INFORMATION
START  Legal Name 
Ü
       Entity ID                                        Revenue ID

       Check All Taxes the Business is Registered for:
      Employer Withholding          Sales Tax                     Public Transportation Assistance Fund (PTA)
      Vehicle Rental (VRT)          Motor Fuels                   Alternative Fuels

      SECTION II RESPONSIBLE PARTY INFORMATION
       Responsible Party Name                                                SSN

       Home Street Address

       City                                                                  State ZIP Code

       Business Title                                   Effective Date End Date Daytime Phone Number

       Signature                                                             DateMM/DD/YYYY
                                    SIGN AFTER PRINTING
       Responsible Party Name                                                SSN

       Home Street Address

       City                                                                  State ZIP Code

       Business Title                                   Effective Date End Date Daytime Phone Number

       Signature                                                             DateMM/DD/YYYY
                                    SIGN AFTER PRINTING
      Use a separate sheet if additional space is needed.
      SECTION III PREPARER INFORMATION
       Preparer Name (Please Print)                     Title                Daytime Phone Number

       Signature                                                             Date
                                    SIGN AFTER PRINTING

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                                                                      Pennsylvania Department of Revenue 

                                                                      Instructions for REV-563 
REV-563 IN (SU) 09-19                Business Trust Fund Taxes Responsible Party Information  

GENERAL INFORMATION                                                                     SUBMISSION
                                                                                                      
Responsible parties are liable for the payment of any trust fund  Mail the completed form to: 
tax liabilities. For trust fund tax purposes, responsible parties     PA DEPARTMENT OF REVENUE 
include but are not limited to persons or officers who have           PO BOX 280901 
active control or authority over a business or organization,          HARRISBURG, PA  17128-0901 
and/or persons who have direct control over finances.  
                                                                      TIP: For quicker processing, email or fax the 
Personal representatives of a decedent’s estate, bankruptcy           completed form to: 
insolvency trustees and lenders that have assumed direct 
control over the borrowers’ finances may be considered                FAX: (717) 787-3708 
responsible parties for PA trust fund tax purposes. Businesses        E-MAIL: ra-btftregisfax@pa.gov 
or organizations making changes to responsible parties are 
required to complete and file an REV-563 with the department.  
                                                                                REGISTRATION METHODS
                                                                                                      
IMPORTANT: An individual who signs an application 
                                                                      IMPORTANT: A change in ownership will require a 
or trust fund tax return for a business or organization 
                                                                      new registration. 
will be considered a responsible party in the absence of any 
contradicting evidence.                                           To register complete the online PA-100, Enterprise 
                                                                  Registration at www.pa100.state.pa.us.  
LINE INSTRUCTIONS
                                                                  To register for Motor and Alternative Fuels, complete an 
                      SECTION I                                   online registration using myPaTH at . www.mypath.pa.gov
                                                        
BUSINESS INFORMATION                                                                    QUESTIONS
                                                                                                      
Enter the legal name of the business, revenue ID and entity 
                                                                  Questions may be directed to the Customer Experience 
ID or federal identification number. 
                                                                  Center by calling (717) 787-1064; services for taxpayers with 
                      SECTION II                                  special hearing and/or speaking needs is available by calling 
                                                                  (800) 447-3020 (TT only). 
RESPONSIBLE PARTY INFORMATION                                     Or, visit our website atwww.revenue.pa.gov.
Enter the responsible party name, social security number, 
home address, business title (i.e. office manager, Chief 
Financial Officer etc…), daytime phone number, effective 
date and end date. This section must be signed by each 
responsible party listed. 

                      SECTION III
                                                        
PREPARER INFORMATION 
The person preparing this form must print their name, sign and 
date the form. Include telephone number and business title. 

www.revenue.pa.gov                                                                                   REV-5631
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