Form Ftb 1063a - Questionnaire Regarding Activities In California - State Of California Franchise Tax Board

STATE OF CALIFORNIA

QUESTIONNAIRE REGARDING

FRANCHISE TAX BOARD

ACTIVITIES IN CALIFORNIA

P.O. BOX 942857

SACRAMENTO, CALIFORNIA 94257-4340

PLEASE COMPLETE

Reference Number

AND MAIL TO THE ABOVE ADDRESS

shown on enclosed letter ___________________

1. EXACT CORPORATION NAME

2. FEDERAL EMPLOYER ID NO.

3. INCORPORATED IN STATE OF

4. DATE INCORPORATED

5. IF NOT INCORPORATED STATE TYPE OF ORGANIZATION:

INDIVIDUAL

GENERAL PARTNERSHIP

CO-OWNERSHIP

OTHER

LIMITED PARTNERSHIP

(EXPLAIN AT ITEM 9)

6A. DATE BEGAN BUSINESS IN CALIFORNIA OR

6B. IF NO LONGER DOING BUSINESS IN CALIFORNIA

DERIVED INCOME FROM CALIFORNIA SOURCES ____________________

INDICATE DATE BUSINESS ACTIVITY CEASED __________________

7. ADDRESS OF PRINCIPAL OFFICE

8. LOCATION OF CALIFORNIA BUSINESS

9. NATURE OF BUSINESS AND DESCRIPTION OF PROPERTY AND/OR SERVICES SOLD

10. DO YOU NOW OR HAVE YOU EVER

11. IF ANSWER TO ITEM 10 IS YES, PLEASE COMPLETE ITEMS (A), (B) AND (C)

FILED CORPORATE RETURNS WITH

THIS DEPARTMENT?

(A) DATE LAST RETURN FILED

(B) CALIFORNIA CORPORATE NUMBER AS SHOWN ON LAST RETURN

YES

NO

(C) EXACT CORPORATION NAME UNDER WHICH LAST RETURN WAS FILED

12. DOES AN AFFILIATED CORPORATION

13. IF ANSWER TO ITEM 12 IS YES, PLEASE COMPLETE ITEMS (A), (B) AND (C)

NOW FILE OR HAS EVER FILED A

COMBINED RETURN WITH THIS DEPARTMENT

REPORTING YOUR ACTIVITIES?

(A) DATE LAST RETURN FILED

(B) CALIFORNIA CORPORATE NUMBER AS SHOWN ON LAST RETURN

YES

NO

(C) EXACT CORPORATION NAME UNDER WHICH LAST RETURN WAS FILED

14. DO YOU OWN OR RENT ANY REAL OR TANGIBLE PERSONAL PROPERTY IN CALIFORNIA?

YES

NO

IF YES, FURNISH AVERAGE YEARLY VALUES BASED ON

ORIGINAL COST (INITIAL FEDERAL TAX BASIS) FOR THE LAST TWO YEARS OR, IF RENTED, THE ANNUAL RENT PAID.

FIRST PRECEDING YEAR

SECOND PRECEDING YEAR

(A) INCOME YEAR ENDED

/

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/

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(B) INVENTORY

TOTAL IN AND

TOTAL IN AND

TOTAL IN STATE

TOTAL IN STATE

(INCLUDE CONSIGNED MERCHANDISE)

OUT OF STATE

OUT OF STATE

(C) REAL PROPERTY OWNED

$

$

$

$

(D) REAL PROPERTY RENTED

$

$

$

$

(E) PERSONAL PROPERTY OWNED

$

$

$

$

(F) PERSONAL PROPERTY RENTED

$

$

$

$

(G) PYHSICAL ADDRESS AND TYPE OF REAL PROPERTY OWNED IN CALIFORNIA

(H) PHYSICAL ADDRESS AND TYPE OF PERSONAL PROPERTY OWNED IN CALIFORNIA

(I)

IF INVENTORY OWNED IN CALIFORNIA, PLEASE INDICATE THE DATE IT WAS ESTABLISHED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . /

/19

15. AMOUNT OF SALARIES, WAGES OR OTHER COMPENSATION PAID IN THE LAST TWO YEARS FOR SERVICES PERFORMED BY EMPLOYEES.

(A) INCOME YEAR ENDED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

/

/19

/

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(B) TOTAL IN AND OUT OF THIS STATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ ________________________________

$ ________________________________

(C) TOTAL IN THIS STATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ ________________________________

$ ________________________________

16. AMOUNT OF SALES MADE DURING THE LAST TWO YEARS

(A) INCOME YEAR ENDED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

/

/19

/

/19

(B) TOTAL IN AND OUT OF THIS STATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ ________________________________

$ ________________________________

(C) TOTAL IN THIS STATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ ________________________________

$ ________________________________

17. NET INCOME (BEFORE NET OPERATING LOSS DEDUCTION) ON FEDERAL INCOME TAX RETURN FOR LAST TWO YEARS

(A) INCOME YEAR ENDED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

/

/19

/

/19

(B) NET INCOME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ ________________________________

$ ________________________________

(Continued on Reverse)

FTB 1063A (REV 7-94) PAGE 1