Form Boe-400-Csu - Application For Consumer Use Tax Account - 2005 Page 2
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1
2BOE-400-CSU (BACK) REV. 1 (10-05)
45. NAMES OF MAJOR SUPPLIERS
46. ADDRESSES (street, city, state, zip code)
47. PRODUCTS PURCHASED
(continued from other side)
OWNERSHIP AND ORGANIZATIONAL CHANGES
48. Are you buying an existing business?
Yes
No
If yes, complete items 51 and 52.
49. Are you changing from one type of business organization to another (for example, from a sole owner to a corporation or from a
partnership to a limited liability company, etc.)?
Yes
No
If yes, complete items 51 and 52.
50. Other Ownership Changes (please describe):
51. FORMER OWNER’S NAME
52. SELLER’S PERMIT NUMBER
53. IF AN ESCROW COMPANY IS REQUESTING A TAX CLEARANCE ON YOUR BEHALF, PLEASE LIST THEIR NAME, ADDRESS, TELEPHONE NUMBER AND THE ESCROW NUMBER
CERTIFICATION
The statements contained herein are hereby certified to be correct to the best knowledge
and belief of the undersigned who is duly authorized to sign this application.
(Signature of owners, partners, corporate officers, or officers or authorized representative of the organization is required.)
NAME (typed or printed)
SIGNATURE
DATE
✍
NAME (typed or printed)
SIGNATURE
DATE
✍
FOR BOARD USE ONLY
SECURITY REVIEW
FORMS
PUBLICATIONS
BOE-8
BOE-400-Y
BOE-598 ($
) or
BOE-1009
PUB 73
PUB DE 44
BOE-162
BOE-519
REQUIRED BY
APPROVED BY
BOE-467
BOE-1241-D
REGULATIONS
RETURNS
REG. 1668
REG. 1698
REG. 1700
CLEAR
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