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Form St-75 - Sales And Use Tax Returns E-File Program - Enrollment Form And Certifications Page 3

ST-75 (7/01) Page 3 of 4

Paid preparer enrollment

Preparer’s firm name

Employer identification number

(or yours, if self-employed)

Preparer’s SSN or PTIN

Mailing address

(number and street or PO Box)

City, State, ZIP code

Paid preparer certification

I, the undersigned, am a paid preparer of sales and use tax returns for

(legal name

of taxpayer as it appears on Certificate of Authority), located at

(business address),

with sales tax identification number

(the taxpayer).

I understand and agree that by virtue of my signature on this enrollment form, each and every return filed by me/my business

on behalf of the taxpayer under the sales and use tax e-file program for filers of Forms ST-100 and ST-102 shall be deemed

to have been signed by me, that my deemed signature on such return shall constitute a certification by me that such return is

true, accurate, and complete, and that each such return shall be treated as the legal equivalent of a signed paper return. (The

declaration of the paid preparer is based on all information of which the preparer has any knowledge.)

I certify that I have examined this application and any accompanying information, and to the best of my knowledge and belief it is

true, correct, and complete.

If the paid preparer named above is other than an individual: I certify that I am acting in the capacity of a corporate officer,

partner (except a limited partner), member, or manager of a limited liability company, and that I have the authority to execute this

Paid preparer certification on behalf of the preparer.

Paid preparer’s signature

Date

Printed name (affix corporate seal, if applicable)

Title

Name of contact representative

Title

Business telephone number

Fax number

Internet email address

Form St-75 - Sales And Use Tax Returns E-File Program - Enrollment Form And Certifications Page 3