Appendix H - Tax and Regulatory Status Form.pdf
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- Solicitation number
- 21240625164751
- Issued by
- Philadelphia County, Dale Borough, Pennsylvania
About this file
Appendix H is a Tax and Regulatory Status and Clearance Statement form required by the City of Philadelphia for vendors submitting proposals to the Department of Aviation for a Digital Content Management System Support contract in Pennsylvania. The form must be completed and submitted with the applicant's proposal to maintain eligibility for contract award. Failure to return the completed form will result in disqualification of the proposal from further consideration by the contracting department.
The form requires applicants to provide their federal employer identification number or social security number, Philadelphia Business Income and Receipts Tax Account Number, and Commercial Activity License Number. Applicants must certify either that they have all required licenses and permits, are current with City tax payments and other indebtedness, and are not in violation of applicable Philadelphia Code provisions, or that they do not currently conduct business or have an economic presence in Philadelphia and will promptly take all necessary steps to achieve compliance if awarded the contract. The form is designated as a confidential tax document not for public disclosure and must be signed by an authorized representative with the applicant's printed name and title.
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Text version
Revised: June, 2012
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 (f/k/a Business Privilege Tax) (if none, state “none”)*
Commercial Activity License Number (f/k/a Business Privilege License) (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
* You can apply for a City of Philadelphia Business Income and Receipts Tax Account Number or a Commercial Activity License on line after you have registered your business on the City’s Business Services website located at http://business.phila.gov/Pages/Home.aspx. Click on “Register” or “Register Now” to register your business.
APPENDIX H
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:
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