Form Rev-203cm - Business Activities Questionnaire Page 5
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5C . I N D E P E N D E N T R E P R E S E N TAT I V E S
Are you a manufacturer’s representative?. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Y E S
N O
If you are a manufacturer’s representative, please attach a list of the names and addresses of each business entity you represent in
P e n n s y l v a n i a .
If you have a contract with a manufacturer’s representative(s) to market your product or service to Pennsylvania customers, please attach a
list of the name(s) and address(es) of each.
D . P E N N S Y LVA N I A M O T O R C A R R I E R A C T I V I T I E S
1 . Is your company a: (Check all that apply)
Common Carrier
Contract Carrier
Private Carrier
Lessor of motor vehicles to other trucking companies
2 . Does your company deliver goods, passengers, products or commodities to destinations in Pennsylvania? . . . . . .
Y E S
NO
2 a . If your answer is yes, indicate when this activity began: (month/year) _ _ _ _ _ _ _ _ _
2 b . How often are deliveries made to Pennsylvania?
_ _ _ _ _ _ _ _ times per week;
_ _ _ _ _ _ _ _ _ times per month; or
_ _ _ _ _ _ _ _ times per year
3 . Does your company pickup goods, passengers, products or commodities at locations in Pennsylvania? . . . . . .
Y E S
NO
3 a . If your answer is yes, indicate when this activity began: (month/year) _ _ _ _ _ _ _ _ _
3 b . How often are pickups made in Pennsylvania?
_ _ _ _ _ _ _ _ times per week;
_ _ _ _ _ _ _ _ _ times per month; or
_ _ _ _ _ _ _ _ times per year
4 . Does your company haul goods, passengers, products or commodities from one location in Pennsylvania to another
location in Pennsylvania? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Y E S
NO
5 . What percentage of your business (loaded mileage) is in Pennsylvania? _ _ _ _ _ _ _ _
If your company is a private carrier, please attach a list of related companies (parent, affiliate and subsidiaries).
Please attach copies of your IFTA Quarterly Tax Returns showing your Pennsylvania miles for the past 4 years.
E . A F F I R M AT I O N
I hereby affirm under penalties prescribed by law that this questionnaire has been examined by me, and to the best of my knowledge and
belief is true, correct, and complete. If prepared by a person other than the taxpayer, statements are based on all information of which pre-
parer has knowledge. The preparer also must complete the information below:
D a t e
Print Name of Owner/Off i c e r /Pa r t n e r
S i g n a t u r e
(
)
(
)
Telephone Number
Fax Number
Company Web site Address (if applicable)
D a t e
Print Name of Preparer
S i g n a t u r e
(
)
(
)
Telephone Number
Fax Number
E-mail A d d r e s s
Please attach additional information to this questionnaire, if it is required to explain your business activities in Pennsylvania. Thank Yo u .
MAIL COMPLETED FORM TO:
REV-203CM (6-06)
PAGE 5
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Parent category: Financial