KOZ Change of Status

KOZ File Number:

(8 digit number assigned by DCED)

KOZ Applicant Name: *

(as listed on original application)

KOZ Address

Address: *

City: *

State: *

Zip/Postal Code: *

Parcel ID Numbers:

Contact Name: *

Contact Number: *

Mailing Address

Address: *

City: *

State: *

Zip/Postal Code: *

Effective Date:

Choose a Reason and Explain

Explanation: *

What code is in the image?: *

Enter the characters shown in the image.

The page was last modified: 11/23/2010

Pennsylvania Department of Community and Econmic Development

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