Form Cbt-2553 - New Jersey S Corporation Or New Jersey Qsss Election Form/form Cbt-2553 - Cert - New Jersey S Corporation Certification - 2005 Page 3

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CBT-2553 - Cert
Mail to:
(8-05)
PO Box 252
Trenton, NJ 08646-0252
(609) 292-1730
State of New Jersey
Division of Taxation
New Jersey S Corporation Certification
This certification is for use by unauthorized foreign (non-NJ) entities that want New Jersey S
Corporation Status. This form MUST be attached to form CBT-2553.
Part I. Corporate Information (Type or Print)
Name of Corporation: ____________________________________________________
Federal Employer Identification Number: ______ - _____________________________
Part II. Corporate Attestation
By signing this statement, the corporation affirms that the corporation has not conducted any activi-
ties within this state that would require the Corporation to file a Certificate of Authority in accordance
with N.J.S.A. 14A :13-3. Specifically, the corporation attests that it is not transacting business in
accordance with the definitions provided in statute.
Print the name and title of the person executing this document on behalf of the Corporation. This
person must be a corporate officer.
Name: ________________________________
Title: ___________________________
Signature: _____________________________
Date: ___________________________
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