Form Ro-1063 - Collection Information Statement For Business

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Form RO-1063
N.C Department of Revenue
Collection Information Statement for Business
Web-fill (Rev. 12-09)
Note: Complete all entry spaces with the current data available or "N/A" (not applicable). Failure to complete all entry spaces may result in rejection of your
request or significant delay in account resolution. Include attachments if additional space is needed to respond completely to any questions.
Section 1. Business Information
1a. Business name
2a. Employer Identification No. (EIN)
2b. Type of Entity (Check appropriate box below)
Partnership
Corporation
Other
1b. Business Street Address
Mailing Address
Limited Liability Company (LLC) classified as a corporation
City
State
ZIP
Other LLC - Include number of members
1c. County
2c. Date Incorporated/Established
mm/dd/yyyy
1d. Business Telephone
3a. Number of Employees
1e. Type of Business
3b. Monthly Gross Payroll
1f. Type of Website
3c. Frequency of Tax Deposits
4. Does the business engage in e-Commerce (internet sales)
Yes
No
Payment Processor
Payment Processor Account Number
(e.g., PayPal, Authorize.net, Google Checkout, etc.), Name and Address (Street, City, State, ZIP code)
5a.
5b.
Credit cards accepted by the business
Type of Credit Card (e.g., Visa, MasterCard, etc.)
Merchant Account Number
Merchant Account Provider Name and Address (Street, City, State, ZIP code)
6a.
Phone
6b.
Phone
6c.
Phone
Section 2. Business Personnel and Contacts
Partners, Officers, LLC, Members, Major Shareholders, Etc.
7a. Full Name
Social Security Number
Title
Home Telephone
Home Address
Work/Cell Phone
City
State
ZIP
Ownership Percentage & Shares or Interest
Responsible for Depositing Taxes
Yes
No
7b. Full Name
Social Security Number
Title
Home Telephone
Home Address
Work/Cell Phone
City
State
ZIP
Ownership Percentage & Shares or Interest
Responsible for Depositing Taxes
Yes
No
7c. Full Name
Social Security Number
Title
Home Telephone
Home Address
Work/Cell Phone
City
State
ZIP
Ownership Percentage & Shares or Interest
Responsible for Depositing Taxes
Yes
No
7d. Full Name
Social Security Number
Title
Home Telephone
Home Address
Work/Cell Phone
City
State
ZIP
Ownership Percentage & Shares or Interest
Responsible for Depositing Taxes
Yes
No
Section 3
Liquid Assets
Business Financial Statement- Page 1

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