Form 1353 - Michigan Department Of Treasury Nexus Questionnaire - 2012 Page 3

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1353, Page 3

Last Four Completed

Number of Days During the 12-Month Taxable Year

Tax Year(s)

Activity Conducted in Michigan

(MM/DD/YY)

2 or more

Yr 1

Yr 2

Conduct training for customers or potential customers.

Yr 3

Yr 4

Yr 1

Provide customers with any kind of technical assistance or service

including, but not limited to, engineering assistance, design service,

Yr 2

quality control, product inspections, or similar services, when one

Yr 3

of the purposes is other than the facilitation of the solicitation of

orders.

Yr 4

Yr 1

Investigate, handle, or otherwise assist in resolving customer

Yr 2

complaints, other than mediating direct customer complaints

when the sole purpose of such mediation is to ingratiate the sales

Yr 3

personnel with the customer.

Yr 4

Yr 1

Yr 2

Provide consulting services.

Yr 3

Yr 4

Yr 1

Yr 2

Solicit, negotiate, or enter into franchising, licensing or similar

agreements.

Yr 3

Yr 4

Beginning January 1, 2008:

8. Is your company a member of a Unitary Business Group (UBG)?

Yes, UBG FEIN (if known):

9. Did your company or the UBG:

A. Actively solicit sales in Michigan? (see page 4 for definition of Actively Solicits)

Yes, enter year(s):

How did your company or the UBG solicit sales in Michigan? Check all that apply.

The use of mail, telephone, and e-mail

Advertising, including print, radio, internet, television, and other media

Maintenance of an internet site over or through which sales transactions occur with persons within Michigan

Other (specify):

B. Have gross receipts of $350,000 or more per year sourced to Michigan? (see page 4 for definition of Gross Receipts and Sourced to Michigan)

Yes, enter year(s):

Beginning January 1, 2012:

10. Does the company have an ownership or beneficial interest in a flow-through entity (directly or indirectly through 1 or more flow-through entities)

which has nexus in this state?

Yes, enter year(s):

I declare, under penalty of perjury, that the information provided in this questionnaire and any attachments is, to the best of my knowledge, true, correct and

complete. If prepared by a person other than an officer, partner or owner of the business, this declaration is based on all information of which you have knowledge.

Signature of Officer, Member, Partner, or Owner

Telephone Number

Date

Print or Type Name and Title

Mailing Address if different than address on Page 1

Signature of Preparer

Telephone Number

Date

Print or Type Name and Title

Preparer’s Mailing Address

For a more complete explanation of Michigan’s Use Tax Nexus Standard, Michigan Business Tax - “Actively Solicits” definition, Michigan Business Tax

Nexus Standard and Michigan Corporate Income Tax Standard, refer to Treasury’s Web site: