Form Reg-1 - Business Taxes Registration Application Page 2
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46. List All Owners, Partners, Corporate Offi cers, or LLC Members Attach a separate sheet if needed.
Name (last, fi rst, middle initial)
Title
Home address line 1 (street)
Home address line 2
City
State
ZIP code
Home telephone number
(
)
SSN
Date of birth
Bank name
/
/
Name (last, fi rst, middle initial)
Title
Home address line 1 (street)
Home address line 2
City
State
ZIP code
Home telephone number
(
)
SSN
Date of birth
Bank name
/
/
Name (last, fi rst, middle initial)
Title
Home address line 1 (street)
Home address line 2
City
State
ZIP code
Home telephone number
(
)
SSN
Date of birth
Bank name
/
/
Name (last, fi rst, middle initial)
Title
Home address line 1 (street)
Home address line 2
City
State
ZIP code
Home telephone number
(
)
SSN
Date of birth
Bank name
/
/
7. Income Tax Withholding
Are you an employer that transacts business or maintains an offi ce in Connecticut and intends
to pay wages to resident employees or nonresident employees who work in Connecticut? ............
Yes
No
If you have a Connecticut tax registration number for withholding for another location
and intend to fi le withholding for this new location under that number, enter that number
here: __________________________ and skip to Section 8; otherwise continue.
Are you an out-of-state company voluntarily registering to withhold Connecticut
income tax for your Connecticut resident employees who work outside of Connecticut? ................
Yes
No
Do you intend to withhold Connecticut income tax from pension plans, annuity plans,
retirement distributions, or gambling distributions? ..........................................................................
Yes
No
Do you pay nonresident athletes or entertainers for services they render in Connecticut? .............
Yes
No
Do you only have household employees and wish to withhold Connecticut income tax? ................
Yes
No
Do you only have agricultural employees and wish to withhold Connecticut income tax? ...............
Yes
No
If Yes, do you fi le federal Form 943, Employer’s Annual Tax Return for Agricultural Employees,
and wish to fi le Form CT-941, Connecticut Quarterly Reconciliation of Withholding, annually? ....
Yes
No
If you answered Yes to any of the income tax withholding questions,
__ __ - __ __ - __ __
enter the date you will start withholding Connecticut income tax. ..................................................
m
m
d
d
y
y
If you use a payroll service, enter the name of the payroll company: _______________________________
REG-1 Rev. 10/11
Page 2 of 4
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Parent category: Financial