PENNSYLVANIA DEPARTMENT OF STATE 
BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS 
                         
    Docketing Statement – New Entity 
                         DSCB:15-134A 
                            (rev. 2/2017) 
                                                                                                                                
1. Entity Name: 
 
In the case of a foreign association which must use an alternate name to register to do business in Pennsylvania, the 
alternate name should be given. 
 
2. Tax Responsible Party 
 
Name of individual responsible for initial tax reports: ______________________________________________________ 
 
Mailing address of individual responsible for initial tax reports: 
 
__________________________________________________________________________________________________ 
 Number and street                               City                         State               Zip                   County 
 
3. Description of Business Activity:  
 
__________________________________________________________________________________________________ 
 
4. FEIN [Employer Identification Number/Federal Tax Identification Number]:  __ __ - __ __ __ __ __ __ __   
 
FEIN enables agencies to confirm that Commonwealth accounts are properly matched and that this request is processed 
without added delay. If the business entity does not currently have an FEIN, it can get a FEIN immediately by applying 
online at irs.gov at the following page http://www.irs.gov/Businesses/Small-Businesses-&-Self-Employed/Employer-ID-
Numbers-EINs. 
 
5. FYE [Tax Year or Fiscal Year End]:     __ __ /__ __   
                                               Month  /  Day 
  
A fiscal year (FY) is a period that a company or government uses for accounting purposes and preparing financial 
statements. For tax purposes, the Internal Revenue Service (IRS) allows companies to be either calendar-year taxpayers or 
fiscal-year taxpayers.  Supply month and day for intended tax year end, e.g. 1/31, 2/28, 3/31, 4/30, 5/31, 6/30, 7/31, 8/31, 
9/30, 10/31, 11/30 or 12/31.