Form 70-001-10-8-1-000 - Registration Application Form - State Of Missisippi

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Mississippi
Form 70-001-10-8-1-000 (Rev.06/10)
Page 1
Registration Application
Route to the
Registration
For Office
For Office
Section
-
-
-
-
-
-
Use Only
Use Only
Sales Tax Only - If more than one physical location, a separate application
Please see instructions for details on completion.
must be completed for each different physical location. If taxpayer is a chain
Incomplete forms will be returned.
type store and filing a masterfile return, then use Form 72-309 to make a
All applicants should complete Sections A ,B and F.
change that affects all accounts.
Also complete any other sections that apply.
SECTION A: Check Tax Account Applying for
Sales/Use Tax
Withholding Tax
Corporate Income Tax
Beer/Tobacco Tax
(Wholesalers & Distributors Only)
Sales Tax
Sales Tax
Corporate Income Tax
Beer Excise Tax
Withholding Tax - Employees
Use Tax
Use Tax
Corporate Franchise Tax
Withholding Tax - Employee Leasing
Tobacco Excise Tax
Taxpayers must file a separate application for permits to sell Beer and Tobacco. See instructions for
Withholding Tax - Gaming
details.
SECTION B: Business Information (all applicants must complete this section - see instructions)
1.
Type of Ownership:
2.
Identification:
Identification:
C Corporation
C Corporation
LLP
Other Government
Federal Employer Identification Number
S Corporation
S Corporation
Partnership - General
Partnership - General
Sole Proprietor
LLC-Partnership
LLC-Partnership
Partnership - Limited
Partnership - Limited
Other: Specify
Social Security Number
*
LLC-Corporation
LLC-Corporation
Federal Government
Federal Government
Single Member LLC-Sole Proprietorship - Put Owners Information in Section C.
Sales Tax Masterfile Number (if any)
Single Member LLC or QSS - List Parent's FEIN ________________________
If there is nexus for income/franchise tax purposes, the parent corporation must file a
Check if claiming Non-Profit status.
3.
separate application for income/franchise taxes and attach a list of all disregarded entities
Attach documentation to substantiate.
that operate within Mississippi showing their names, FEIN's and sales and use tax numbers.
4.
Legal Name (Owner's name, if sole proprietor)
5.
Trade Name (if different)
Headquarters Address or
Street address, do not enter P.O.Box.
6.
Home Address - if Sole Proprietor
State
County
ZIP
City
7.
Mailing Address
Street Address or P.O.Box
ZIP
City
County
State
8.
Physical Address
Street address, do not enter P.O.Box.
County
City
State
ZIP
9.
Phone Number
Fax Number
(
)
(
)
Pager / Cell Number
E-mail Address
(
)
Secondary Phone
Fax Number
(
)
(
)
10.
Description or nature of business
SECTION C: For Corporations, LLC's and Partnerships Only
11.
State of Incorporation
12.
Date admitted or authorized to do business in Mississippi.
13.
Company is a publicly traded company. ( Yes
No
)
If yes, under what symbol.
Calendar Yr.
14.
Basis of reporting:
Fiscal Yr. (List)
If C Corp, S Corp, LLC, LLP, or Partnership, list names and home addresses of officers, directors, managing partners, or members who
15.
have any responsibility for fiscal management of the organization and stockholders or members owning 10% or more of the stock or
interest in a corporation or LLC. (If more space needed, add additional page.)
Address Information
Social Security
Name
Title
%Owned
Number
Physical Address
City
State
Zip
*
Disclosure Statement and Privacy Act Notice
*This information will be used for identification and in the administration of state tax laws. The Department of Revenue is authorized to collect
the information pursuant to 42 U.S.C. § 405(c)(2)(c)(i). Any applicant who refuses to provide the required information will be denied the
permit. See Miss. Code Ann. § § 27-77-1(e) and 27-77-11.

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