Form Pse - Extension Request For The Alabama Business Privilege Tax Return And Annual Report - 2003

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RESET FORM
A
D
R
LABAMA
EPARTMENT OF
EVENUE
Extension Request For The Alabama
2003
PSE
Business Privilege Tax Return and Annual Report
THIS FORM MUST BE SIGNED AND ALL SECTIONS MUST BE COMPLETED
Type of business entity (must check one):
For Balance Sheet Year:
Beginning
C Corporation
S Corporation
Other
______/______/________
Regular C Corporation
Regular S Corporation
Real Estate Investment Trust
(mm/dd/yyyy)
Insurance Company (See definitions)
Insurance Company (See definitions)
Limited Liability Entity
Ending
Financial Institution Group Member
Financial Institution Group Member
Business Trust
______/______/________
(mm/dd/yyyy)
LLE Taxed as Corporation
LLE Taxed as Corporation
Disregarded Entity
CY (Calendar Year)
LEGAL ENTITY NAME (PLEASE TYPE OR PRINT)
FY (Fiscal Year)
SY (Short Year)
MAILING ADDRESS
FEIN
RECEIVING STAMP
CITY, STATE, AND ZIP CODE
(This Space For Use By Alabama Department of Revenue)
FEDERAL BUSINESS CODE NUMBER (NAICS)
DOES THIS REPRESENT A CHANGE
Yes
OF ADDRESS?
1a County of incorporation or organization for all Alabama entities. . . .
1a
1b State or country of incorporation or organization . . . . . . . . . . . . . . .
1b
2a Date of qualification or registration in Alabama for foreign entities. .
2a
A
2b Date of incorporation or organization for all entities . . . . . . . . . . . . .
2b
T
(
)
2c Telephone number of the taxpayer . . . . . . . . . . . . . . . . . . . . . . . . . .
2c
T
A
3 Name of registered agent in Alabama. . . . . . . . . . . . . . . . . . . . . . . .
3
C
FEIN or social security number . . . . . . . . . . . . . . . . . . . . . . . . . . . .
H
Street address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C
City, state and zip code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
H
E
4 Name of president or primary member/partner . . . . . . . (update
)
4
C
Social security number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
K
Street address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
H
City, state and zip code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
E
R
5 Name of secretary or secondary member/partner . . . . (update
)
5
E
Social security number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Street address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
City, state and zip code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6 Kind of business done in Alabama . . . . . . . . . . . . . . . . . . . . . . . . . .
6
7 Principal place of business in Alabama. . . . . . . . . . . . . . . . . . . . . . .
7
City, state and zip code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8 Kind of business done generally . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
9 Principal office and place of business if outside State of Alabama. .
9
City, state and zip code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
FOR DEPARTMENT USE ONLY
10
10 Secretary of State annual report fee $10 (corporations only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11
11 Privilege tax due* (minimum $100) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12 Payment due (sum of lines 10 and 11)
12
(Electronic Funds Transfer is not available for these taxes) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I authorize a representative of the Department of Revenue to discuss my return and attachments with my preparer.
UNDER PENALTIES OF PERJURY, I declare that I have examined this return and accompanying schedules and statements and, to the best of my knowledge and
belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Please
Sign Here
Your
Signature**
Title
Date
Date
Phone number
Preparer’s social security no.
Paid
Preparer’s
signature
Preparer’s
Firm’s name (or yours,
E.I. No.
Use Only
if self-employed)
ZIP Code
and address
**Paid preparers may sign in lieu of an officer IF a power of attorney is on file with the Department of Revenue or attached to this return.
*To avoid late payment penalties, 90% of the actual liability must be paid with this extension request.

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