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9Were the assets or activities of the business acquired in whole or in part from a prior business entity?
Yes
No ( If “Yes”, give predecessor’s name, address and acquisition date. )
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Acquisition Date |
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MM/DD/YYYY |
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P.O. Box, Street and Number |
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City or Town |
County |
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ZIP Code |
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10 |
Has the business held title to any real estate in the last five years from the date of this application? |
Yes |
No |
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lIf “Yes”, complete Schedule A (last page).
lIf you currently hold title to real estate in PA, complete Schedule B (last page).
11 |
Will the assets or activities of the business be transferred to another? |
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If “Yes”, complete: |
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A. |
Corporation |
Yes |
No |
F. Other |
Yes |
No |
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Name of New Owner |
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B. |
Partnership |
Yes |
No |
Explain: |
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Street Address of New Owner |
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C. |
Proprietorship |
Yes |
No |
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D. |
Liquidating Trust |
Yes |
No |
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City |
State |
ZIP Code |
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E. |
Association |
Yes |
No |
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12Purpose of Clearance Certificate (check appropriate block):
A. Dissolution of Corporation or Association through Department of State.
B. Dissolution of Corporation or Association through Court of Common Pleas. Date Court was petitioned and county:
(date) MM/DD/YYYY(county)

C. Withdrawal of Foreign Corporation through Department of State

D. Merger or consolidation of two or more Corporations or Associations where surviving Corporation or Association is not subject to the
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jurisdiction of Pennsylvania. (See 15 Pa C.S. § 139.) |
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E. Bulk Sale Clearance Certificate under Section 1403 of the Fiscal Code. Sale date: |
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MM/DD/YYYY |
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Copy of settlement statement: |
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Corporation Tax Purposes |
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Employer Withholding Tax Purposes |
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Sales, Use and Hotel Occupancy Tax Purposes |
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Unemployment Compensation Tax Purposes |
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STATEMENT OF AUTHORIZATION |
I authorize the PA Department of Revenue to disclose, verbally or in written form, all tax filings, payments or delinquencies
requested by the buyer or his representatives for the bulk sale transfer provision. |
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MM/DD/YYYY |
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Authorized by |
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Title |
Date |

F. Foreign Corporation Clearance Certificate under the provisions of the Act of 1947, P.L. 493, Contract Number and Political Subdivision:
13Location of business records, available for audit of Pennsylvania operations.
P.O. Box, Street and Number |
City |
State |
ZIP Code |
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Telephone Number |
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14List any matters pending with the PA Department of Revenue (e.g. petitions, appeals):
15 |
Did the business ever, within the Commonwealth of PA: |
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MM/DD/YYYY |
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(a) |
........................................................Engage in the sale of soft drinks or soft drink syrup |
Yes |
No |
Period |
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to |
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(b) |
Own or lease and operate diesel-powered motor vehicles on PA highways? |
Yes |
No |
Period |
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to |
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(c) |
..........................Engage in the sale of diesel fuel to motor vehicles using PA highways? |
Yes |
No |
Period |
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to |
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(d) |
Engage in the sale or lease of tangible personal property since Sept. 1, 1953? |
Yes |
No |
Period |
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to |
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(e) |
File PA Unemployment Compensation Reports? |
Yes |
No |
Period |
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If “Yes”, give Account Number |
(See question 8k.) |
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16Have you terminated your business activities in Pennsylvania? 
Yes 
No
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If “Yes”, give distribution of assets date: |
MM/DD/YYYY |
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If “No”, explain: |
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If a Foreign Corporation, have you terminated business in the state of your incorporation? |
Yes No |
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17number of employees and total gross payrolls during the last five operating years (as reported to the Social Security Administration):
yeAR |
TOTAL eMPLOyeeS |
PA |
TOTAL GROSS |
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eMPLOyeeS |
PAyROLL |
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GROSS PAyROLL |
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18Have the officers received any remuneration, in cash or other other form, for services performed in Pennsylvania during the current calendar year or during any of the preceding four calendar years?
yes
no
19Were any remunerated services performed for the business in PA, which you believe did not constitute “employment” as defined in the PA unemployment Compensation Law?
yes
no
if “yes”, explain:
20A. Average number of stockholders during the last five years:
B.number of stockholders as of this report:
C.List names and home addresses of stock transfer agents who have handled the corporation’s stock:
name:Address:
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d. Were all shares presented and property redeemed from any stock called for redemption or retired? |
yes |
no |
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21 |
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The figures below must agree with the last corporate tax report filed with the PA department of Revenue. |
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date of Report: |
MM/DD/YYYY |
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Total Liabilities: |
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Total Assets: |
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Total equity (net worth): |
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22 |
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A. List the amount of corporate bonds issued and still outstanding as of this report. Show each issue separately and include name and |
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address of any transfer or paying agents. |
Agent |
number of Outstanding Bonds |
Amount |
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issue |
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B. List names and addresses of transfer or paying agents not listed above who have handled corporate bond issues. |
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name: |
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Address: |
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23Have you consumed or used in Pennsylvania any tangible personal property or acquired such, after March 6, 1956, on which no PA sales or use tax was paid? if “yes”, please explain:
yes
no
24do you have within your custody, possession or control any abandoned and unclaimed (escheatable) funds or assets such as dividends, payroll, deposits, outstanding checks, stock certificates, unidentified deposits, accounts payable debit balances, gift certificates, outstanding debentures or interest, royalties, mineral rights or funds due missing shareholders or other unclaimed amounts payable?
yes
no
25Has the business filed a PA Abandoned and unclaimed Property Report for the preceding year?
yes
no
26CeRTiFiCATiOn: i certify that the information provided (including Schedules, if applicable) on this application has been examined by me and is, to the best of my knowledge, true and correct. (Certification must agree with individuals listed in question 4.)
Print name |
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Original Signature |
Signature of Officer – Please sign after printing |
Print name |
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Original Signature |
Signature of Officer – Please sign after printing |
This form will serve as an application for clearances from both the PA department of Revenue and PA department of Labor & industry.
nOTe: l Submit typed original to the PA department of Revenue (address on Page 1) and one copy to the PA dePARTMenT OF LABOR & induSTRy, OFFiCe OF uneMPLOyMenT COMPenSATiOn TAX SeRviCeS, e-GOveRnMenT uniT, LABOR & induSTRy BuiLdinG, ROOM 916, 651 BOAS ST., HARRiSBuRG PA 17121. Retain a copy for taxpayer’s record.
ldirect telephone inquiries to the PA department of Revenue at 717-783-6052 or at 717-346-2001. Services for taxpayer with special hearing /speaking needs can be accessed at 1-800-447-3020. Call the PA department of Labor & industry at 866-403-6163, Option 2 or 717-783-3545 for services for the hearing impaired.
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SCHEDULE A - STATEMENT OF ACQUISITION AND/OR DISPOSITION OF PENNSYLVANIA REAL ESTATE WITHIN FIVE YEARS FROM THE DATE OF THIS APPLICATION
Name of Transferee (EE) or Transferor (OR).
Indicate each by symbol EE or OR.
Property Location by
Local Political Subdivision
& County
Original Cost |
County |
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Land |
Building |
Assessed Value |
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Actual Consider- |
Actual Monetary Worth |
Amount of PA Realty |
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ation including |
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(Market Value) |
Stamps Affixed to |
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Encumbrance |
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at Time of Transfer* |
Document** |
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Assumed* |
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SCHEDULE B STATEMENT OF ALL PENNSYLVANIA REAL ESTATE NOW OWNED
Property Location by Local Political Subdivision & County
Original Cost |
County |
Actual Consider- |
Actual Monetary Worth |
Amount of PA Realty |
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ation including |
(Market Value) |
Stamps Affixed to |
Land |
Building |
Assessed Value |
Encumbrance |
at Time of Transfer * |
Document** |
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Assumed* |
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List all real estate now owned in PA that the business will dispose of prior to or at the time of the action for which a clearance is required. If under agreement of disposition, attach copy of executed agreement for each property so affected.
*Complete if applicable. If transfer represents less than a full fee-simple interest in the property, explain on a separate sheet of paper. ** If no realty transfer tax was paid, explain on attached sheet or in “Explanation” column above.
If application is for a Bulk Sale Clearance Certificate, attach a list of PA properties that will be retained. For each property, provide the complete address, including county, date of acquisition and nature of property (residential, industrial, acreage, commercial or farmland). If none, state none.