
4.
YES
NO DOES THIS ENTERPRISE WANT TO BECOME A PENNSYLVANIA LOTTERY RETAILER?
SECTION 5 – BUSINESS STRUCTURE
CHECK THE APPROPRIATE BOX FOR QUESTIONS 1, 2 & 3. IN ADDITION TO SECTIONS 1 THROUGH 10, COMPLETE THE SECTION(S) INDICATED.
1.
SOLE PROPRIETORSHIP (INDIVIDUAL)
GENERAL PARTNERSHIP
ASSOCIATION LIMITED LIABILITY COMPANY
CORPORATION (Sec. 11)
LIMITED PARTNERSHIP
BUSINESS TRUST
STATE WHERE CHARTERED
GOVERNMENT (Sec. 13)
LIMITED LIABILITY PARTNERSHIP
ESTATE
RESTRICTED PROFESSIONAL COMPANY
JOINT VENTURE PARTNERSHIP
STATE WHERE CHARTERED
2.
PROFIT
NON-PROFIT IS THE ENTERPRISE ORGANIZED FOR PROFIT OR NON-PROFIT?
3.
YES
NO IS THE ENTERPRISE EXEMPT FROM TAXATION UNDER INTERNAL REVENUE CODE (IRC) SECTION 501(c)(3)? IF YES,
PROVIDE A COPY OF THE ENTERPRISE'S EXEMPTION AUTHORIZATION LETTER FROM THE INTERNAL REVENUE SERVICE.
SECTION 6 – OWNERS, PARTNERS, SHAREHOLDERS, OFFICERS, AND RESPONSIBLE PARTY INFORMATION
PROVIDE THE FOLLOWING FOR ALL INDIVIDUAL AND/OR ENTERPRISE OWNERS, PARTNERS, SHAREHOLDERS, OFFICERS, AND RESPONSIBLE PARTIES. IF STOCK IS PUBLICLY
TRADED, PROVIDE THE FOLLOWING FOR ANY SHAREHOLDER WITH AN EQUITY POSITION OF 5% OR MORE.
ADDITIONAL SPACE IS AVAILABLE IN SECTION 6A, PAGE 11.
1. NAME 2. SOCIAL SECURITY NUMBER 3. DATE OF BIRTH * 4. FEDERAL EIN
5.
OWNER
OFFICER 6. TITLE 7. EFFECTIVE DATE 8. PERCENTAGE OF 9. EFFECTIVE DATE OF
PARTNER
SHAREHOLDER OF TITLE OWNERSHIP OWNERSHIP
RESPONSIBLE PARTY %
10. HOME ADDRESS (street) CITY/TOWN COUNTY STATE ZIP CODE + 4
11. THIS PERSON IS RESPONSIBLE TO REMIT/MAINTAIN:
SALES TAX
EMPLOYER WITHHOLDING TAX
MOTOR FUEL TAXES
WORKERSʼ COMPENSATION COVERAGE
* DATE OF BIRTH REQUIRED ONLY IF APPLYING FOR A CIGARETTE WHOLESALE DEALERʼS LICENSE, A SMALL GAMES OF CHANCE DISTRIBUTOR LICENSE, OR A SMALL GAMES
OF CHANCE MANUFACTURER CERTIFICATE.
SECTION 7 – ESTABLISHMENT BUSINESS ACTIVITY INFORMATION
REFER TO THE INSTRUCTIONS ON PAGES 20 & 21 TO COMPLETE THIS SECTION. COMPLETE SECTION 17 FOR MULTIPLE ESTABLISHMENTS.
1. ENTER THE PERCENTAGE THAT EACH PA BUSINESS ACTIVITY REPRESENTS OF THE TOTAL RECEIPTS OR REVENUES AT THIS ESTABLISHMENT. LIST PRODUCTS OR
SERVICES ASSOCIATED WITH EACH BUSINESS ACTIVITY AND THE PERCENTAGE REPRESENTING THE TOTAL RECEIPTS OR REVENUES.
Accommodation & Food Services
Agriculture, Forestry, Fishing, & Hunting
Art, Entertainment, & Recreation Services
Communications/Information
Construction (must complete question 3)
Domestics (Private Households)
Educational Services
Finance
Health Care Services
Insurance
Management, Support & Remediation Services
Manufacturing
Mining, Quarrying, & Oil/Gas Extraction
Other Services
Professional, Scientific, & Technical Services
Public Administration
Real Estate
Retail Trade
Sanitary Service
Social Assistance Services
Transportation
Utilities
Warehousing
Wholesale Trade
TOTAL 100%
DEPARTMENT USE ONLY
ENTERPRISE NAME
5
2. ENTER THE PERCENTAGE THAT THIS ESTABLISHMENTʼS RECEIPTS OR REVENUES REPRESENT OF THE TOTAL PA RECEIPTS OR REVENUES OF THE ENTERPRISE.
______________ %. SINGLE ESTABLISHMENT ENTERPRISES ENTER 100%. MULTIPLE ESTABLISHMENT ENTERPRISES ENTER PERCENTAGE OF ENTERPRISE (SEE SECTION 17).
3. ESTABLISHMENTS ENGAGED IN CONSTRUCTION
MUST
ENTER THE PERCENTAGE OF CONSTRUCTION ACTIVITY THAT IS NEW AND/OR RENOVATIVE AND THE PERCENT-
AGE OF CONSTRUCTION ACTIVITY THAT IS RESIDENTIAL AND/OR COMMERCIAL.
___________________ % NEW
+
__________________ % RENOVATIVE = 100%
___________________ % RESIDENTIAL
+
__________________ % COMMERCIAL = 100%
PA BUSINESS ACTIVITY
%%
%
PRODUCTS OR SERVICES
ADDITIONAL
PRODUCTS OR SERVICES
PA-100 (03-09)