Application To Register For Income Tax Withholding And Sales And Use Tax Permit - North Dakota Office Of State Tax Commissioner Page 2

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FOR OFFICE USE ONLY
16. Complete if you acquired the business in whole or in part
a. Date of acquisition
Month
Day
Year
b. Prior owner's business name and address
Yes
No
c. Prior owner's sales/use tax number
Is prior owner still in business?
No
Yes
17. Do you currently have or have you had a sales and use tax permit in North Dakota?
Permit No.
18. Do you anticipate your monthly sales tax liability to be less than $50.00?
Yes
No
19. Estimated number of employees in North Dakota and total wages paid for the current year.
Amount of wages
Number of employees
Yes
No
If seasonal, give period of operation
20. Is business seasonal or part time?
If business is temporary, give approximate time period of business activity in North Dakota
through
21. Name of individual to contact for sales tax matters
Phone No.:
Name of individual to contact for withholding tax matters
Phone No.:
22. Application completed by:
Date:
Signature:
(Authorized Individual)
Print name:
Phone No:
I declare under the penalties of North Dakota Century Code ch. 12.1-11-02, which provides for a Class A misdemeanor for making a false statement in a governmental
matter, that this application, including any accompanying schedules and statements, has been examined by me and to the best of my knowledge and belief is a true,
correct and complete application.
23. Application must be signed by:
* Sole Proprietorship - Owner
* Partnership or Association - Each partner or member
* Corporation - President, Vice President, Secretary or Treasurer
* Limited Liability Company - Governor, Manager or Member if member-controlled
Liability of Corporate Officer or LLC Manager, Governor or Member
North Dakota Law makes the corporate officer, manager or governor of an LLC, or member of a member-controlled LLC having
control, or supervision of, or charged with the responsibility for filing the required withholding tax or sales and use tax returns
and payments personally liable for the business' failure to file the returns or remit the tax. When this responsibility changes, this
office must be notified. Dissolution of a Corporation or LLC does not discharge the officer's, manager's, governor's or member's
liability to file a return or remit the tax due.
State law provides Corporations and LLCs the option of posting a bond or cash deposit instead of having its Corporate officer or
LLC manager, governor or member held personally liable for taxes due. Please contact our office if your Corporation or LLC
wishes to exercise this option.
I acknowledge I have read the above statements regarding liability.
Sales/Use Tax:
Printed Name
Signature
Title
Social Security No.
Withholding Tax:
Printed Name
Signature
Title
Social Security No.
For Office Use Only
Mail to: Office of State Tax Commissioner
Business Registration
600 E. Boulevard Ave., Dept. 127
Bismarck, ND 58505-0599
Phone: (701)328-3125 - Withholding
Phone: (701)328-3474 - Sales
Website:
28213
Rev. 8/04

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