REV-563 - Responsible Party Information Form
PREPARER’S NAME TITLE
DAYTIME TELEPHONE EXT.
SIGNATURE E-MAIL ADDRESS DATE
SECTION I.
REV-563 AS (4-11)
RESPONSIBLE PARTY INFORMATION FORM
LEGAL NAME
ACCOUNT ID
ENTITY ID
PLEASE INDICATE ALL TAXES YOUR BUSINESS IS REGISTERED FOR:
EMPLOYER WITHHOLDING LIQUID FUEL
SALES TAX CORPORATION TAX
BOX #: ___________
PTA/VRT
SECTION II.
INDIVIDUAL OWNER(S), PARTNER(S) OR CORPORATE OFFICER(S) RESPONSIBLE FOR TAX RETURN INFORMATION. OWNERSHIP CHANGE REQUIRES A NEW PA-100 REGISTRATION FORM.
RESPONSIBLE PARTY NAME
SSN
HOME ADDRESS TITLE DAYTIME TELEPHONE EXT.
EFFECTIVE DATE END DATE
SIGNATURE
RESPONSIBLE PARTY NAME
SSN
HOME ADDRESS TITLE DAYTIME TELEPHONE EXT.
EFFECTIVE DATE END DATE
SIGNATURE
RESPONSIBLE PARTY NAME
SSN
HOME ADDRESS TITLE DAYTIME TELEPHONE EXT.
EFFECTIVE DATE END DATE
SIGNATURE
RESPONSIBLE PARTY NAME
SSN
HOME ADDRESS TITLE DAYTIME TELEPHONE EXT.
EFFECTIVE DATE END DATE
SIGNATURE
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