Form 100 - Designation Of Individual 2014

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100
D
O
I
FORM
ESIGNATION
F
NDIVIDUAL
2014
Calendar Year
EIN/SSN
: #
Any person owning an interest in a lease granted by the Navajo Nation, or engaged in any business
activity whatsoever within the Navajo Nation, must register with the Office of the Navajo Tax
Commission (ONTC). Please refer to instructions when completing this form. Please print legibly.
Business Name
:
Nature of Business :
1. Designee(s) Information
Name
:
Title
:
Mailing Address
:
City, State, Zip
:
Telephone Number :
Fax Number
:
E-mail Address
:
2. Business Office
3. Navajo Nation Address
1
2
(if different from Section 1)
(if different from Sections
&
)
Address
:
Address
:
Telephone :
Telephone :
4. This form applies to :
5. Type of Business :
(check one only)
(check one only)
BAT
SEV
Corporation
Partnership
HOT
TOB
Joint Venture
Sole Proprietorship
FET
SALES
Other (Specify)
6. Month End of Accounting Year:
7. Accounting Records kept on:
Cash _______
Accrual _______ , basis.
Physical Address of where records
are located (Street, City, and State) :
8. Is your company related to any other company or person owning an interest in a lease granted by the Navajo Nation OR
engaging in any business activity whatsoever within the Navajo Nation?
If yes, please list company or person.
I declare that the information contained in this document and any attachments thereto is true and correct to the
best of my knowledge and belief pursuant to all Navajo Nation laws and regulations.
x
/
/
Taxpayer or Duly Authorized Agent Signature
Print or Type Name
Telephone Number
Date
ONTC
Form 100-2014
Revised: 11/12/13

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