City of Philadelphia - 2018 Tax Year Subsidy Self-Reporting Form

Primary Business Contact Information

In accordance with Bill #160015, approved by Philadelphia City Council and signed by Mayor Kenney on September 15, 2016, businesses are subject to certain self-reporting requirements if, in the previous calendar year:

1) The business was located in a Keystone Opportunity Zone (KOZ) and had more than $2 million in gross revenues.

2) The business received $50,000 or more in financial assistance through the authority or approval of the City.

If you are unsure whether or not your business is subject to the self-reporting requirement, please see our list of Frequently Asked Questions.

Please answer these questions as thoroughly and accurately as possible. The information businesses provide will be aggregated into a report to help inform City Council and the public about how well economic development incentives tie to job creation. Additionally, the Department of Commerce uses this survey to collect voluntary information from businesses, such as how the use of economic development incentives influences business decisions, and ways that businesses choose to support their communities.

If you have received this form, you MUST verify whether or not your business triggered the reporting requirement for 2018 by completing Section 1 and certifying your form.

The deadline for reporting is May 1, 2019.

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* 1. Please provide the primary information of the business, located in the City of Philadelphia, for which you are completing this form. (Note that if the business is a parent company with subsidiaries, please aggregate the subsidiaries' information and report it all under the parent company.)

Name of Business:

Business Street Address:

Business Zip Code:

Business Phone Number:

Federal Employer Identification Number (EIN):

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* 2. Which 2-digit NAICS code (sector) best describes your business? (If you are unsure of your NAICS code, please click here.)

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* 3. Please provide the contact information of the person filling out this form.

Name

Title

Company

Relationship to Business

Phone Number

Email Address

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* 4. Your business is completing this form because:

It is located in a Keystone Opportunity Zone (KOZ) and had $2 million or more in gross revenues in 2018.

It received financial assistance of $50,000 or more through City approval in 2018.

It is not required to complete this form.

12% of survey complete.