Form Ador 10193 - Transaction Privilege/use/withholding Tax License Update
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2Arizona Department of Revenue
License & Registration Section
PO Box 29032 • Phoenix AZ 85038-9032
Phoenix: (602) 542-4576 • Toll-free: (800) 634-6494 (from area codes 520 and 928)
TRANSACTION PRIVILEGE/USE/WITHHOLDING TAX LICENSE UPDATE
Taxpayer or Legal Business Name on Current License Number (Please print)
License Number(s)
EIN
SECTION A. License Type
Transaction Privilege Tax (TPT)
Withholding/Unemployment Tax (if hiring employees)
Use Tax
SECTION B. Changes Requested / Fees
STATE FEE:
Please check boxes below to indicate the change in your account, and complete Sections C through G to verify or correct
all license information. Asterisked (
) changes to Transaction Privilege Tax accounts are subject to a fee of $12 per location
*
CITY FEE(S):
(from back page)
for the state fee and city fees are listed on the back of this form. There are no fees for Use Tax or Withholding registration.
TOTAL FEE(S):
Business name or DBA name change
Duplicate license
*
*
Mailing address change
Add city license (see other side)
*
Business location change
*
Reinstate Effective Date
Additional business or rental location(s) fi ling consolidated reports
*
Cancel effective date
Corporate Offi cers
SECTION C. BUSINESS NAME AND ADDRESS
Legal Business Name / Owner / Employing Unit
Business or “Doing Business As” Name
Mailing Address (Street Name or PO Box), City, State, Zip
Country
E-mail address
Business Phone Number
Fax Number
Physical Location Business or Rental (NOT a PO Box)
County
Check here if this is added location
SECTION D. IDENTIFICATION OF OWNER Partners, Corporate Offi cers, Members (or Managing Members) or Offi cials of this employing unit
A. Name (Last, First, MI)
B. Soc. Sec. No.
C. Title
D. % Owned
E. Complete Residence Address
F. Phone Number
If the owner, partners, corporate offi cers or combination of partners or corporate offi cers, members and/or managing members own or control more than
50% of another business in Arizona, attach a list of the businesses, percentages owned and unemployment insurance account numbers.
SECTION E. LOCATION OF TAX RECORDS
Location of Tax Records (Street Address, City, State and ZIP code)
Name of Company or Person to Contact
Phone Number
ADOR 10193 (7/11)
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