CITY OF PHILADELPHIA DEPARTMENT OF REVENUE

                                                      CHANGE FORM
           USE TO UPDATE ACCOUNT INFORMATION OR TO CANCEL A TAX LIABILITY
                                         MAIL THE COMPLETED CHANGE FORM TO:
CITY OF PHILADELPHIA, DEPARTMENT OF REVENUE, P.O. BOX 1410, PHILADELPHIA, PA, 19105-1410
                                                      OR FAX TO:  215-686-6635

         PHONE:  215-686-6600            E-MAIL:  revenue@phila.gov            INTERNET:  www.phila.gov/revenue

Businesses complete  Sections 1 and    2 to add a tax, request payment coupons or to close a business account.   For a change
of entity you must cancel your account and apply for a new Tax Account Number and Commercial Activity License.  Contact
the department to obtain an application or to register on-line visit our web site.  For property subject to Use and Occupancy
Tax complete   Section 3.  Individuals complete   Section 4 for School Income Tax or   Section 5 for Employee Earnings Tax.   
Section 6 must be completed for all requests including the signature of the preparer of this form.

Section 1 - Business Tax Registration Information.
Currently Registered Business Name and Address                             Corrected Business Name and Address

City Account Number              Employer Identification Number              City Account Number Employer Identification Number
                                 -                                                                                -
                 Social Security Number                                                 Social Security Number
                       --                                                                        --
           Spouse's Social Security Number                                     Spouse's Social Security Number
                       --                                                                        --
Section 2  - Add  a tax, request payment          If your business has closed, enter the last day of business:
coupons or to cancel an account.                                                                                      --

If your business never                                               To add a new tax type, enter the start date:     --
materialized, check here:
                                         ADD          CANCEL         COUPONS                                      ADD  CANCEL COUPONS
AMUSEMENT TAX                                                                PARKING TAX
BUSINESS INCOME & RECEIPTS TAX                                               USE & OCCUPANCY TAX
HOTEL TAX                                                                    VALET PARKING TAX
NET PROFITS TAX                                                              VEHICLE RENTAL TAX
OUTDOOR ADVERTISING TAX                                                      WAGE TAX
Section 3 - For property subject to Use and Occupancy Tax.
Property Address                                                                     Business U&O Tax Account Number
                                                                                                                      -
                                                                                        Property Account Number

                                                                                                 Cancellation Date
Use and Occupancy Tax Mailing Address  (If different from Property Address)
                                                                                                 --
                                                                                                 Date of Purchase
                                                                                                 --

Check Reason for Cancellation:
                 Sold                    Residential                         Name of New Property Owner
                 Vacant                  Other (Explain in Section 6)
                                                                                                                      83-E669 Rev. 10-22-2012

Section 4                                      SCHOOL INCOME TAX
If the preprinted information listed on your tax return is incorrect, use this form to make the necessary corrections.  For example, if your spouse
is deceased and you filed jointly with your spouse, use the Change Form to indicate your name and Social Security number.
Currently Registered Taxpayer Name and Address              Corrected Taxpayer Name and Address

              Social Security Number                                        Corrected Social Security Number
              --                                                                    --
              Spouse's Social Security Number                               Corrected Spouse's Social Security Number
              --                                                                    --

                                                                                               Cancellation Date
Reason        Moved out of Philadelphia                     Spouse Filing Separately
Cancellation  Deceased.  Enter date of death________________
for                                                         No taxable Income              --

Section 5                                      EMPLOYEE EARNINGS TAX
Currently Registered Taxpayer Name and Address              Corrected Taxpayer Name and Address

              Social Security Number                                        Corrected Social Security Number
              --                                                                    --

Reason        Moved out of Philadelphia        Employer now withholding tax                Cancellation Date
          for                                                                       --
Cancellation  Deceased                         No longer employed

Section 6                    State the reason for submitting this change form:

                             Contact information must be completed for all change requests.

              Form Completed By (print name):                                 Date

              Signature:                                                      Telephone #

              E-mail Address                                                  Fax #