APPENDIX B TAX FORM.pdf

Appendix B - City of Philadelphia Tax and Regulatory Status and Clearance Statement

CITY OF PHILADELPHIA TAX AND REGULATORY

STATUS AND CLEARANCE STATEMENT

FOR APPLICANTS

THIS IS A CONFIDENTIAL TAX DOCUMENT NOT FOR PUBLIC DISCLOSURE

This form must be completed and returned with Applicant’s proposal in order for Applicant to be eligible for award of a contract with the City. Failure to return this form will disqualify Applicant’s proposal from further consideration by the contracting department. Please provide the information requested in the table, check the appropriate certification option and sign below:

Applicant Name

Contact Name and Title

Street Address

City, State, Zip Code

Phone Number

Federal Employer Identification Number or

Social Security Number:

Philadelphia Business Income and Receipts

Tax Account Number (if none, state “none”)

Commercial Activity License Number (if none, state “none”)

____ I certify that the Applicant named above has all required licenses and permits and is current, or has made satisfactory arrangements with the City to become current with respect to the payment of City taxes or other indebtedness owed to the City (including, but not limited to, taxes collected by the City on behalf of the School District of Philadelphia), and is not in violation, or has made satisfactory arrangements to cure any violation, or other regulatory provisions applicable to Applicant contained in the Philadelphia

Code.

___ I certify that the Applicant named above does not currently do business, or otherwise have an economic presence in Philadelphia. If Applicant is awarded a contract with the City, it promptly will take all steps necessary to bring it into compliance with the City’s tax and other regulatory requirements.

Authorized Signature Date

Print Name and Title