Business Activity Questionnaire Form - New Hampshire
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2NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
AUDIT DIVISION - (603) 271-3400
Business Activity Questionnaire
Name and Address of Business Organization (Company):
DBA (if different than above):
Federal Employer Identification Number (FEIN) or Social Security Number (SSN):___________________________________________
List all Related Entities/Affiliates (Include FEIN/SSN for each and indicate if any of the related entities/affiliates file or have filed
Business Profits or Business Enterprise Tax returns. Attach a separate list if necessary):_____________________________________
___________________________________________________________________________________________________________
Nature of Business:__________________________________________ Tax Periods Covered:
Name and Title of Taxpayer Contact:________________________________ Taxpayer Contact Telephone #:____________________
State of Incorporation: _______________
Date of Incorporation: _______________ State of Commercial Domicile: _____________
Type of Business Organization: [
] Corporation
[
] Combined
[
] Partnership [
] LLC
[
] Proprietor
Are you an IRC § 501(c)(3)? _______ If yes, stop here, attach a copy of your IRS determination letter and return this form to the NH
Dept of Revenue contact listed at the end of this form.
Check the correct response to the questions below as they relate to the above business organization. In the event that a
"yes" or "no" answer is inappropriate, attach an explanation.
YES
NO
1.
Are you registered with the NH Secretary of State? If yes, effective date: ________________
2.
Have you filed with NH Department of Employment Security? If yes, date of first filing: _____________
3.
Have you filed with NH Road Toll Administration
If yes: a) date of first filing: ______________ b) enter miles traveled in NH for most recent year: ______________
4.
Does your company have any owned or leased vehicles registered with NH Division of Motor Vehicles?
If yes, indicate date of initial registration:________________________
5.
Does your company have NH rental or lease income?
6.
Do you derive income from NH intangible sources such as franchise fees, royalties, debt instruments, or any
other contractual agreements?
7.
Does your company own, rent, or lease any of the following type property in NH?
Office..................................................................................................................................................................
Warehouse (public or private) ............................................................................................................................
Inventory (including consignment goods and/or work-in-progress) ....................................................................
Depreciable assets or Leasehold improvements ...............................................................................................
Land (in use or available for use) .......................................................................................................................
Buildings ............................................................................................................................................................
Transportation Equipment ..................................................................................................................................
Machinery and Equipment. ................................................................................................................................
Other (specify) __________________________________________________________________________
8.
Does your company have any resident sales personnel in NH?
9.
Does your company perform any business services (accounting, management review, programming, legal or
other related or similar functions) in NH?
10. Does your company have any company employees/independent contractors performing services (technical,
repair, installation, assembly, training, warranty or other) at locations in NH?
11. Does your company have any goods, property or equipment (e.g., signs, display cases, tools & dies, molds,
patents, etc.) on loan in NH?
12. Does your company have employees/independent contractors who travel to or live in NH for the
purposes of offering any continuing services to customers in NH? (Describe activities on a separate sheet.)
13. When working in NH, do company employees/independent contractors have authority to make collections, assist in
collection efforts on delinquent accounts or repossess your company's product in NH?
AU-15
Revised 4/2009
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