Form Dtf-24.1 - Application For Connecticut/new York State Simplified Sales And Use Tax Reporting

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DTF-24.1 (5/05)
Application for Connecticut/New York State
OR-233 (Revised 5/05)
Simplified Sales and Use Tax Reporting
Department Use Only
Please read all instructions before completing - print or type (black or blue ink)
1. Legal name of business
DLN
(owner’s name, partners’ names, or corporate name)
2. Physical location of place of business
NY
(number and street; see instructions)
CT
City
State
ZIP code
County
3. DBA/Trade name
4. Telephone number
NAICS
(if different from legal name - line 1)
(
)
5. Mailing address
(number and street - if different from line 2)
City
State
ZIP code
6. Type of business organization:
Limited liability company
Sole proprietorship
Not-for-profit corporation
(check one of the following 3 types):
Partnership
Exempt organization
Sole proprietorship
Corporation
Trust
Partnership
Governmental
Other
Corporation
(specify):
7. Describe in detail the type of business you operate:
8. Enter the federal employer identification number (FEIN) assigned to
your business.
FEIN
..............................
If the business does not have an FEIN, enter the owner’s or responsible
partner’s social security number (SSN) at right.
SSN ............................
9. Current sales tax registration numbers:
10. Effective date
(see instructions)
New York State number
/
/
(mm/dd/yyyy)
Connecticut number
11A. If your principal place of business is in New York State, do you maintain a business location in Connecticut?
Yes
No
11B. If your principal place of business is in Connecticut, do you maintain a business location in New York State?
Yes
No
Affirmation
The undersigned hereby applies for registration under Connecticut/New York State Simplified Tax Reporting Program and understands that
there will be an exchange of such information between Connecticut and New York State as may be necessary to register the vendor for the
program and to administer the program.
The undersigned agrees, that upon approval of this registration, the vendor shall be subject to the laws of both Connecticut and New York
State for sales and use tax purposes.
12. I certify that the above statements are true:
Signature
Title
(Owner, partner, or responsible officer)
Telephone (
)
/
/
Name
Date
(Please print)
E-mail address
COA Post Date
Regist Date
Multi St Ind
Multi St Eff Date
Mail Agent
Fl Freq CD
Schdls Aux Schdls Sup COA
NYS
use only

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