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SECTION I. STATE/LOCAL SALES TAX LICENSE CANCELLATION INFORMATION
Sales Tax License is Non–Transferable
SALES TAX ACCOUNT ID
BUSINESS DISCONTINUED
NO TAXABLE SALES FOR: REPORTING AND PAYING UNDER OTHER REASONS:
ANOTHER ACCOUNT ID NUMBER:
STATE/LOCAL TAX AFTER DATE STATE/LOCAL TAX
STATE/LOCAL TAX
PHILADELPHIA LOCAL TAX AFTER DATE ACCOUNT ID
PHILADELPHIA LOCAL TAX
ALLEGHENY COUNTY LOCAL TAX AFTER DATE
ALLEGHENY COUNTY LOCAL TAX
SECTION II. EMPLOYER WITHHOLDING TAX CANCELLATION INFORMATION
EMPLOYER WITHHOLDING TAX REASON FOR CANCELLATION: REPORTING AND PAYING UNDER
ACCOUNT ID ANOTHER ACCOUNT ID NUMBER:
BUSINESS CLOSED OR SOLD DATE EMPLOYER WITHHOLDING TAX
NO LONGER HAS EMPLOYEE(S) SUBJECT TO PA PERSONAL INCOME TAX DATE ACCOUNT ID
OTHER DATE
SECTION III. PUBLIC TRANSPORTATION ASSISTANCE FUND TAXES AND FEES/VEHICLE RENTAL TAX INFORMATION PTA License is Non –Transferable
PTA TAX ACCOUNT ID BUSINESS DISCONTINUED REPORTING AND PAYING UNDER VEHICLE RENTAL TAX INFORMATION:
ANOTHER ACCOUNT ID NUMBER:
PTA TAX ACCOUNT ID SALES TAX ACCOUNT ID
DATE VRT ACCOUNT ID BUSINESS DISCONTINUED DATE
BUSINESS/ACCOUNT CANCELLATION FORM
ENTITY ID (EIN/SSN):
LEGAL NAME:
TRADE NAME:
REV-1706 AS (04-10)
SECTION IV. CIGARETTE DEALER’S LICENSE CANCELLATION INFORMATION Cigarette Dealer’s License is Non-Transferable
CIGARETTE DEALER’S LICENSE NUMBER NAME SSN
DATE DAYTIME TELEPHONE EXT. SIGNATURE/TITLE E-MAIL ADDRESS
( )
MAIL TO: PA DEPARTMENT OF REVENUE
PO BOX 280901
HARRISBURG, PA 17128-0901
PLEASE SIGN AFTER PRINTING
PRINT FORM
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