RETURN IN FIVE (5) DAYS
                                                                                                         EMPLOYER’S FEDERAL IDENTIFICATION NUMBER
  CITY OF HIGHLAND PARK – INCOME TAX DEPARTMENT
  NEW BUSINESS AND EMPLOYER’S WITHHOLDING REGISTRATION                                                    HP    —
  READ INSTRUCTIONS ON THE REVERSE BEFORE FILLING OUT THIS FORM
1. TRADE NAME
2.  EMPLOYER’S NAME (GIVE OWNER’S TRUE NAME
  IF DIFFERENT FROM TRADE NAME ABOVE)
3.  ADDRESS OF PRINCIPLE PLACE OF BUSINESS
3A. HOME ADDRESS AND SOCIAL SECURITY NUMBER
  (Individual Ownership Only)
4.  CHECK TYPE OF ORGANIZATION:                                             OTHER         5. LOCAL TELEPHONE NO. 6. NO. OF EMPLOYEES
    INDIVIDUAL OWNER           PARTNERSHIP        CORPORATION         (ATTACH EXPLANATION)
7.  DATE BUSINESS ACQUIRED BY        MONTH DAY YEAR                   GIVE THE DATE YOU FIRST PAID WAGES MONTH DAY YEAR
  EMPLOYER SHOWN IN ITEM 2 ABOVE                               8.   SUBJECT TO HIGHLAND PARK WITHHOLDING
9.  WAS THIS BUSINESS PREVIOUSLY OPERATED BY ANOTHER EMPLOYER? 10. IF ANSWER TO ITEM 9 IS “YES”, GIVE EMPLOYER’S NAME AND IDENTIFICATION NO. 
                                                                    IF KNOWN.
               YES                          NO 

 SIGNATURE                                                                     TITLE DATE
  ACCOUNTING PERIOD ENDING                                                                   HP-SS-4

                                                INSTRUCTIONS

           Each employer withholding City of Highland Park Income Tax Department from employees’ wages should 
  register with the Income Tax Department. For the convenience of the employer, the Federal Identification Number 
  assigned to the employer by the Federal District Director of Internal Revenue will be used for the City of Highland 
  Park Income Tax Department records. If an employer does not have a Federal Identification Number at the time of 
  filing the City of Highland Park Income Tax reports, application can be made to the Federal District Director of 
  Internal Revenue on Federal Form SS-4 for a number.
           When for any reason the Federal Identification Number is not required, an identification number will be 
  assigned by the City of Highland Park Tax Department if an employer is assigned a Federal Number at a later date, 
  he must notify the City Income Tax Department of the Federal Number assigned. The employer will then be notified 
  to discontinue the City of Highland Park Identification Number and use the Federal number for all future City 
  withholding purposes.