CITY OF PHILADELPHIA                                                          APPLICATION FOR
     DEPARTMENT OF REVENUE                               EMPLOYEE EARNINGS (WAGE) TAX ACCOUNT

                 Your Social Security/ Individual Tax Identification Number is your Employee Earnings Tax Account Number. 
                         Do not file this application if Philadelphia Wage  axTwas withheld on all compensation.
APPLICANT'S NAME                                                                            SOCIAL SECURITY/ INDIVIDUAL TAX IDENTIFICATION  NUMBER
                                                                                                           --
HOME ADDRESS

CITY                                                                                        STATE          ZIP CODE

DAYTIME TELEPHONE NUMBER                  FAX NUMBER                                        E-MAIL ADDRESS

EMPLOYER'S NAME                                                                             EMPLOYER'S FEDERAL TAX IDENTIFICATION NUMBER
                                                                                                          -
EMPLOYER'S ADDRESS

CITY                                                                                        STATE          ZIP CODE

EMPLOYER'S TELEPHONE NUMBER               FAX NUMBER                                        E-MAIL ADDRESS

EMPLOYMENT START DATE                     ARE YOU STILL EMPLOYED BY THIS EMPLOYER?          IF NO, ENTER SEPARATION DATE
            --                                           YES                   NO                         --
     I HEREBY CERTIFY that the statements contained herein and in any supporting schedule or exhibit are true and correct to the best of my
     knowledge and belief.  I understand that if I knowingly make any false statements herein, I am subject to penalties as prescribed by law.
APPLICANT'S SIGNATURE                                                                                      DATE

                                          MAIL COMPLETED APPLICATION TO:
                                                         CITY OF PHILADELPHIA
                                                         DEPARTMENT OF REVENUE
                                                         1401 JOHN F. KENNEDY BLVD.
                                                         PHILADELPHIA, PA 19102
                                          TO REGISTER ONLINE GO TO www.phila.gov/revenue 
                                                         TELEPHONE: (215)686-6600

                                                                                                                        83-T-104A Rev. 08-08-2019

      APPLICATION FOR EMPLOYEE EARNINGS (WAGE) TAX ACCOUNT

                           To apply online, go to www.phila.gov/revenue.

Note:  Under Act 48 of 1994, all employers having a place of business in Pennsylvania must withhold City Wage Tax
from Philadelphia Residents.

                                            WHO MUST FILE

Residents of Philadelphia who received compensation from which City wage tax was  not deducted on total wages.

Non-residents of Philadelphia who received compensation for services performed in Philadelphia and wage tax
was   not deducted on total wages.

                                          TAXABLE COMPENSATION

Gross Compensation includes wages, commissions, tips, bonuses, severence pay, sick and/or vacation pay, non-cash
compensation, and military reserve  pay not  including active duty.    Pension plan contributions (such  as  401k
contributions) are subject to wage tax and are not deductible from gross taxable compensation.

                                                  TAX RETURNS

An annual reconciliation return, due April 15 following the calendar year, will be mailed to you. You must include all 
applicable W-2 forms with your return.  A coupon book containing prepayment coupons for each quarterly payment will be 
mailed to you separately.  To make a current year quarterly payment go to www.phila.gov/revenue and click "Tax Returns" 
then "Print Payment Coupon."  If you want a paper coupon mailed, contact Taxpayer Services at 215-686-6600.

                                            FILING FREQUENCY

                    Quarter                       Period Covered                  Due Date*
                    1                       January, February, March              April 30
                    2                             April, May, June                July 31
                    3                       July, August, September               October 31
                    4                       October, November, December           January 31

                * If the due date is on a holiday or weekend, payment is due on the next business day.

                                          Interest and Penalty (General)

Effective January 1, 2014, the monthly interest rate is .416% and the penalty rate is 1.25% for all taxes except Liquor and
Real Estate.

For tax returns due on or before December 31, 2013 - Failure to pay by the due date will result in the imposition of interest
and penalty. The tax remaining unpaid after the due date is subject to interest at the rate of 1% per month or fraction of
each month until paid. The unpaid tax is also subject to penalty at rates that increase incrementally in accordance with the
following table:

                    Elapsed Time after Due Date                    Rate of Penalty

                    1st through 3rd month                1% per month or fraction thereof
                    4th through 6th month                2% per month or fraction thereof
                    7th through 9th month                3% per month or fraction thereof
                    10th through 12th month              4% per month or fraction thereof

Total penalty after 12 months is 30%. Thereafter, penalty is charged at the rate of 1 1/4% per month or fraction thereof.

Payments made after the due date that do not include applicable interest and penalty will be automatically pro-rated
between principal, interest and penalty.

                                                                                                      83-T-104B Rev. 08-08-2019