Form Dtf-17 - Application To Register For A Sales Tax Certificate Of Authority Page 5

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DTF-17 (12/10) Page 5 of 6

Section G — Responsible person(s)

(continued)

Name

Business title

(first, middle initial, last, suffix)

Home address

City

U.S. state /Canadian province

ZIP/ Postal code

Country

(number and street; not a PO Box)

SSN

Home phone number

Effective date of assuming responsibility

( )

Primary duties

E-mail address

All responsible persons must complete the following — except those in

Ownership

Profit distribution percentage, if different than

C corporations, government entities, trusts, and estates ........................... percentage if over 5%:

ownership percentage and if over 5%:

Name

Business title

(first, middle initial, last, suffix)

Home address

City

U.S. state /Canadian province

ZIP/ Postal code

Country

(number and street; not a PO Box)

SSN

Home phone number

Effective date of assuming responsibility

( )

Primary duties

E-mail address

All responsible persons must complete the following — except those in

Ownership

Profit distribution percentage, if different than

C corporations, government entities, trusts, and estates ........................... percentage if over 5%:

ownership percentage and if over 5%:

Section H — Tax preparer information —If you have no preparer leave this section blank and continue with section I.

Tax preparer’s or firm’s name

Preparer’s or firm’s EIN (if known)

Preparer’s NYTPRIN (if known)

Preparer’s or firm’s address (number and street)

City

U.S. state/Canadian province

ZIP/Postal code

Country

Preparer’s E-mail address

Preparer’s telephone number

Preparer’s PTIN (if known)

( )

f you want sales tax information mailed to this preparer, mark an X in the box .............................................................................................

Section I — Signature of responsible person – Complete all fields

(see instructions)

I certify that the above statements are true, complete, and correct, and that no material information has been omitted. I make these

statements with the knowledge that willfully providing false or fraudulent information with this document may constitute a felony or other

crime under New York State Law, punishable by a substantial fine and possible jail sentence. I also understand that the Tax Department is

authorized to investigate the validity of any information entered on this document.

Name

SSN

Date

Signature

Title

Daytime telephone number