Form Dtf-24.1/or-233 - Application For Connecticut/new York State Simplified Sales And Use Tax Reporting - 2005

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DTF-24.1 (1/05)

Application for Connecticut/New York State

OR-233 (Revised 1/05)

Simplified Sales and Use Tax Reporting

DRS use only

Department Use Only

Please read all instructions before completing - print or type (black or blue ink)

TX REG TR AD

1. Legal name of business

DLN

(owner’s name, partners’ names, or corporate name)

2. Address of principal place of business

Create

(number and street)

T - (

)

P - (

)

M - (

)

3. City

State

ZIP code

County

4. DBA/Trade name

5. Telephone number

(if different from legal name - line 1)

(

)

NAICS

6. Mailing address

(if different from line 2)

Name

Number and street

City

State

ZIP code

Type of business organization:

Individual

Partnership

Corporation

Governmental

Trust

Exempt organization

Limited liability company

(check one of the following 3 types)

Not-for-profit corporation

Sole proprietorship

Partnership

Corporation

Other

(specify)

Describe in detail the type of business you operate:

Enter the federal employer identification number (FEIN) assigned to your business

FEIN ........................

If the business does not have an FEIN, enter the owner’s or responsible partner’s

social security number at right.

Social security number

10.

Current sales tax registration numbers:

New York State number

Connecticut number

11A.

If your principal place of business is in New York State, do you maintain a business location in Connecticut?

Yes

11B.

If your principal place of business is in Connecticut, do you maintain a business location in New York State?

Yes

Affirmation

The undersigned hereby applies for registration under Connecticut/New York Simplified Tax Reporting Program and understands that there will be an

exchange of such information between Connecticut and New York State as may be necessary to register the vendor for the program and to administer the

program.

The undersigned agrees that upon approval of this registration, the vendor shall be subject to the laws of both Connecticut and New York State for sales and

use tax purposes.

12.

I certify that the above statements are true:

Signature

(Owner, partner, or responsible officer)

Name

Title

Date

(Please print)

COA Post Date

Regist Date

Multi St Ind