Form Cr-16 - Business Tax Application - Kansas Page 4
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4PART 11 - OWNERSHIP DISCLOSURE AND SIGNATURE STATEMENT
List ALL owners, partners, corporate
officers and directors.
Provide the personal information and signatures of all persons who have control or authority over how business funds or
assets are spent. If more space is needed, please attach additional pages.
Certification: To the best of my knowledge and belief the information on this application is true, correct and complete. If
the business fails to report or pay appropriate state taxes, any individual who is responsible for the tax authorizes the
Secretary of Revenue or his/her designee to research the credit history of the business or that individual.
X
Printed full proper name of owner, partner or corporate officer
Signature of owner, partner or corporate officer
Date
Title
Title
SSN
Home Address
Home Address
(Street Address)
(City)
(State)
(Zip Code)
Home Telephone (
)
Percentage of Ownership
Percentage of Ownership
%
%
Yes
Yes
Do you have control or authority over how business funds or assets are spent?
Do you have control or authority over how business funds or assets are spent?
No
No
Date that you became the owner, partner or corporate officer of this business:
Month _______________ Day ______ Year ______
X
Printed full proper name of owner, partner or corporate officer
Signature of owner, partner or corporate officer
Date
Title
Title
SSN
Home Address
(Street Address)
(City)
(State)
(Zip Code)
Home Telephone (
)
Percentage of Ownership
Percentage of Ownership
%
%
Yes
Yes
Do you have control or authority over how business funds or assets are spent?
No
No
Date that you became the owner, partner or corporate officer of this business:
Month _______________ Day ______ Year ______
X
Signature of owner, partner or corporate officer
Date
Printed full proper name of owner, partner or corporate officer
Title
Title
SSN
Home Address
(Street Address)
(City)
(State)
(Zip Code)
Home Telephone (
)
Percentage of Ownership
Percentage of Ownership
Percentage of Ownership
Percentage of Ownership
%
%
%
%
Yes
Yes
Yes
Yes
Do you have control or authority over how business funds or assets are spent?
No
No
No
No
Date that you became the owner, partner or corporate officer of this business:
Month _______________ Day ______ Year ______
X
Signature of owner, partner or corporate officer
Date
Printed full proper name of owner, partner or corporate officer
Title
Title
SSN
Home Address
(Street Address)
(City)
(State)
(Zip Code)
Home Telephone (
)
Percentage of Ownership
Percentage of Ownership
Percentage of Ownership
Percentage of Ownership
%
%
%
%
Yes
Yes
Yes
Yes
No
No
No
No
Do you have control or authority over how business funds or assets are spent?
Date that you became the owner, partner or corporate officer of this business:
Month _______________ Day ______ Year ______
Return this form and payment to: Kansas Department of Revenue
915 SW Harrison St., Topeka, KS 66625-9000 or Fax to: 785-291-3614
For assistance: Phone: 785-368-8222
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