(PT) 11-19 (FI)
                                                            NONWITHHOLDING OF 
                        REV-291                             PA INCOME TAX 
                                                            APPLICATION

                                                            PURPOSE OF          REV-291
  Withholding Required. A partnership or PA S corporation is required to withhold Pennsylvania personal income tax on the PA-source 
  income of each nonresident partner, member or shareholder.         Exception. A partnership or PA S corporation is not required to withhold 
  Pennsylvania personal income tax on income reported to a partner, member or shareholder that is one of the following and gives 
  the partnership or PA S corporation a completed and a signed REV-291, Nonwithholding of PA Income Tax Application: 
      • A PA S corporation or other corporation                                 •  A clearing agency (or its nominee) or a broker or financial
      • A partnership or other unincorporated enterprise                           institution (or its nominee) that holds an interest in a
                                                                                   partnership or PA S corporation as a nominee on behalf of
      • A pension, profit-sharing or charitable trust
                                                                                   one of the above.
      • A resident individual, estate or trust
  This application should be filed with the partnership or PA S corporation. Do not submit this form to the department.
      SECTION I          IDENTIFICATION
START  1a. Name of Beneficial Owner of Partnership or PA S corporation Interest                     1b. Taxpayer Identification Number
Ü                                                                                                                        9 DIGIT - NO DASH
   1c. Permanent Street Address                                       City                           State                ZIP Code

   1d. Current Mailing Address, if Different than Permanent Address*  City                           State                ZIP Code

   1e. Withholding Agent (Enter Name of Partnership or PA S Corporation)                            1f. Taxpayer Identification Number
                                                                                                                         9 DIGIT - NO DASH
   1g. Current Mailing Address*                                       City                           State                ZIP Code

  *Include apartment or suite number or post office box if mail is not delivered to street address.
                                                     COMPLETE SECTION II OR        SECTION III
      SECTION II         CERTIFICATION BY BENEFICIAL OWNER
  The beneficial owner of an interest in the withholding agent is (mark applicable oval): 
        A PA S corporation or other corporation 
        A pension, profit-sharing or charitable trust, a business trust, a partnership or other unincorporated enterprise
        A resident individual, estate or trust
      SECTION III        CERTIFICATION BY NOMINAL OWNER
   3a. Name of Nominal Owner of Partnership or PA S Corporation Interest                            3b. Taxpayer Identification Number
                                                                                                                         9 DIGIT - NO DASH
       3c. Current Mailing Address*                                   City                           State                ZIP Code

  *Include apartment or suite number or post office box if mail is not delivered to street address.
  3d. The nominal owner holds its interest in withholding agent as a nominee on behalf of the beneficial owner. 
            The beneficial owner is (mark applicable oval): 
        A PA S corporation or other corporation 
        A pension, profit-sharing or charitable trust, a business trust, a partnership or other unincorporated enterprise
        A resident individual, estate or trust
      SECTION IV         REVOCATION OR TERMINATION OF PRIOR WITHHOLDING EXEMPTION CERTIFICATE
        Mark this oval if you are revoking a prior Nonwithholding of PA Income Tax Application.     
  Under penalties of perjury, I certify that to the best of my knowledge and belief the information on this form is correct.
   Print or Type Name of Beneficial Owner or Authorized Representative  Signature                                         Date        MM/DD/YY
                                                                                Please Sign Your Return after printing.

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