Form Ow-12 - Withholding For Nonresident Royalty Interest - Oklahoma

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Form OW-12
Revised 5-2012
Withholding for Nonresident Royalty Interest
Mail to: Oklahoma Tax Commission • 2501 North Linclon Boulevard • Oklahoma City, OK 73194-0010
Office Use Only
How is this business owned?
1
Individual
General Partnership
Limited Partnership
Oklahoma Corporation
Foreign Corporation
Limited Liability Company (LICO)
Approval
Other (explain)
Denied
Status
Federal Employerʼs Identification Number:
2
Business Phone Number with Area Code: (
)
3
FR
WH
Ownership Information:
4
Name of Individual, Partnership or Corporation
Social Security Number (If individual)
Mailing Address (street number, post office box, or rural route and box number)
City
State
Zip
County
Names of Partners, Corporate Officers, and Managing Officer:
5
(a)
Name (Last, First, Middle Initial)
Social Security Number
Title
Mailing Address (street number, post office box, or rural route and box number)
City
State
Zip
County
(b)
Name (Last, First, Middle Initial)
Social Security Number
Title
Mailing Address (street number, post office box, or rural route and box number)
City
State
Zip
County
(c)
Name (Last, First, Middle Initial)
Social Security Number
Title
Mailing Address (street number, post office box, or rural route and box number)
City
State
Zip
County
(If more space is needed, attach additional pages)
Date you began/will begin withholding for nonresident royalty interest .......... (month/day/year) ________/ ________ / ________
6
What FEI number will you use to report withholding tax? (If different than item 2) .................... __________________________
7
8
Trade name of Business
9
Physical Location (Street and number or directions; NOT P.O. Box or Rural Route Number)
City
State
Zip
County
10
Name and title of officer or employee responsible for remitting withholding for nonresident royalty interest
Phone Number
11
Address to which forms are to be mailed
City
State
Zip
A sole owner, general partner, corporate officer or authorized representative must sign this application.
I, the undersigned applicant or authorized representative, declare under the penalties of perjury that I have examined this application and attachments and, to the best of my knowledge, the facts set
forth are true and correct, and that the requirements hereunder will be carried out in accordance with the laws of the State of Oklahoma and the rules and regulations of the Oklahoma Tax Commis-
sion. I further acknowledge and agree that sales, withholding, and motor fuel taxes are trust funds for the State of Oklahoma and that any use of these trust funds other than timely remittance to the
State of Oklahoma is embezzlement and can result in criminal prosecution.
Type or print name and title
Signature
Date
Mandatory inclusion of Social Security and/or Federal Employerʼs Identification Numbers is required on forms filed with the Oklahoma Tax Commission pursuant to Title 68 of the Oklahoma Statutes
and regulations thereunder, for identification purposes, and are deemed part of the confidential files and records of the Oklahoma Tax Commission. The Oklahoma Tax Commission is not required
to give actual notice of changes in any state tax laws.

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