Questionnaire 21-004: Activities Within Iowa For A Corporation, Partnership Or Llc Page 2

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Page 2
10. Please enclose a copy of your annual report or Federal 10k form for the latest period available.
Please Note: All information provided is confidential under Iowa Code and Rules.
11. Enter name and Iowa mailing address for 5 largest customers located in Iowa:
(If you have no customers indicate this by stating “no Iowa customers”)
Name/Address
End User / Reseller / Other
______________________________________________________________
________________
______________________________________________________________
________________
______________________________________________________________
________________
______________________________________________________________
________________
______________________________________________________________
________________
12. Enter the requested information for the preceding three years for which tax information is available.
MM/DD/YY
Sales Shipped
All Sales
Net Federal Taxable Income
into IA
Before Net Operating Loss
______________
_______________
______________
__________________
______________
_______________
______________
__________________
______________
_______________
______________
__________________
Please give detailed answers to all remaining questions. If needed, attach additional explanation sheets.
If a document answers the question, submit the document.
Answers will apply to each tax period indicated on page one. Employees who are most familiar with
activities described by each question should complete this questionnaire. It is important that all people
helping to answer this questionnaire are listed in question 30.
Please mark Yes or No for all that apply
13. Does your company solicit sales by
Yes
No
a. Company employee(s) traveling in Iowa on company business?
_______
_______
b. Telephone or telemarketing?
_______
_______
c. Mail order (catalog or publications)?
_______
_______
d. Participating in Iowa trade shows?
_______
_______
e. Independent representative(s)?
_______
_______
f. Independent dealer(s)?
_______
_______
g. Independent contractor(s)?
_______
_______
h. Other
_______
_______
If yes to items e - h, complete the information at the top of page 3.
21-004b (04/04/11)

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