BOE-400-ELF (S1) REV. 5 (3-04)
STATE OF CALIFORNIA
APPLICATION FOR ELECTRONIC RETURN ORIGINATOR
BOARD OF EQUALIZATION
TO PARTICIPATE IN THE BOE E-FILING PROGRAM
PLEASE PRINT OR TYPE – INSTRUCTIONS ARE AVAILABLE ON THE REVERSE OF THIS FORM
1. THIS APPLICATION IS (please check one)
Sales and Use Tax Accounts
New
Revised
Reinstatement
FOR
Motor Fuels Accounts
2. FEDERAL EMPLOYER IDENTIFICATION NUMBER
FOR BOARD USE ONLY – CLIENT IDENTIFICATION NUMBER
3. LEGAL NAME OF ELECTRONIC RETURN ORIGINATOR
4. BUSINESS NAME (if other than on line above)
5. PERMANENT MAILING ADDRESS (include street or P.O. Box, city, state, zip code)
6. BUSINESS ADDRESS (if other than above; include street, city, state, zip code)
7. BUSINESS CONTACT INFORMATION
Business Phone: (
)
Business FAX: (
)
E-Mail Address:
IP Address:
URL:
8. TYPE OF OWNERSHIP ENTITY
Sole Proprietorship
General Partnership
Limited Liability Company (LLC)
Corporation
Limited Partnership
Other (please explain)
9. CORPORATE/LLC INFORMATION (if applicable)
State of Incorporation or Organization:
Corporate or LLC Number:
Date of Incorporation or Organization:
California Secretary of State Number:
10. CONTACT REPRESENTATIVE (please provide name, title, phone number and e-mail address)
11. PLEASE ANSWER THE FOLLOWING QUESTIONS BY CHECKING THE APPROPRIATE BOX:
YES
NO
Has the firm or any corporate officer, partner, owner or responsible official:
a. Been convicted of a monetary crime?
b. Failed to file California personal or business tax returns, or pay liabilities?
c. Been convicted of any criminal offense under the U.S. Internal Revenue or
California Revenue and Taxation Codes?
If the answer is yes to any of the above inquiries, please attach a written explanation describing all pertinent facts.
12. APPLICATION AGREEMENT
Under penalty of perjury, I declare that I have examined this application and any accompanying information, and to the best of
my knowledge and belief it is true, correct, and complete. This firm and its employees will comply with all the provisions of the
California Board of Equalization’s E-Filing Handbook and Specifications for Electronic Return Originators of California Sales and
Use Tax, or the California Board of Equalization’s Motor Fuels Electronic Filing Program Handbook and Specifications (EDI
Guide), and related publications, including fraud prevention and detection guidelines for all years of participation. I understand
that if this firm is sold or its organizational structure is changed, acceptance for participation is not transferable and a new
application must be filed. I further understand that noncompliance will result in the firm or individual no longer being allowed to
participate in the program. I am authorized to make and sign this statement on behalf of the firm.
13. NAME AND TITLE OF THE FIRM’S OFFICIAL AND/OR PRINCIPAL OWNER (type or print)
14. SIGNATURE OF THE FIRM’S OFFICIAL AND/OR PRINCIPAL OWNER
DATE
Please return the completed application to:
E-Filing Program Coordinator, State Board of Equalization
P.O. Box 942879, Sacramento, CA 94279-0093
CLEAR
PRINT