Form Ador 74-4002 - Arizona Joint Tax Application
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4ARIZONA JOINT TAX APPLICATION
UC-001 (3/03)
DEPT. OF REVENUE
DEPT. OF ECONOMIC SECURITY
1600 W Monroe
PO BOX 6028
PHOENIX AZ 85007
PHOENIX AZ 85005-6028
IMPORTANT: See attached instructions before completing this application. You must complete each section below or your application will be returned. For licensing
questions on Transaction Privilege, Withholding or Use call (602) 542-4576 or 1-800-634-6494 (from area codes 520 and 928). For questions on Unemployment Tax
call (602) 248-9396 or e-mail uit.status@mail.de.state.az.us. Please return to: Department of Revenue, 1600 W Monroe, Phoenix AZ 85007.
I. LICENSE TYPE
Transaction Privilege Tax (TPT)
Withholding/Unemployment Tax (if hiring employees)
Use Tax
TPT For Cities ONLY
II. TYPE OF OWNERSHIP OR EMPLOYING UNIT
Individual
Association
Other (Please Explain)
Partnership
Trust
Limited Liability Company
Limited Liability Partnership
Corporation
State of Inc.______ Date of Inc.______________
Sub Chapter S
* Tax exempt organizations must attach a copy of the
Internal Revenue Service letter of determination.
III. BUSINESS INFORMATION
LEGAL BUSINESS NAME / OWNER / EMPLOYING UNIT
BUSINESS OR DBA NAME
IN CARE OF
MAILING ADDRESS (STREET, ROUTE NO. OR P.O. BOX)
E-MAIL ADDRESS
CITY
STATE
ZIP CODE
BUSINESS PHONE NUMBER
(
)
PRIMARY ARIZONA LOCATION OF BUSINESS (or Physical Address if not in AZ) STREET, CITY, STATE, ZIP CODE
ARIZONA COUNTY
IS YOUR BUSINESS LOCATED ON AN INDIAN RESERVATION?
YES
NO
IF YES, PLEASE TELL US WHICH ONE. ______________________________________
For additional locations, complete the supplement form on page 4.
NAICS CODE
DESCRIPTION OF BUSINESS (MUST INCLUDE TYPE OF MERCHANDISE SOLD OR TAXABLE ACTIVITY OR TYPE OF EMPLOYMENT)
DATE BUSINESS STARTED IN ARIZONA
DATE SALES BEGAN
DATE EMPLOYEES FIRST HIRED
AVERAGE NO. OF EMPLOYEES
FEDERAL EMPLOYER IDENTIFICATION NUMBER (REQUIRED FOR
TPT FILING METHOD:
CASH RECEIPTS
ACCRUAL
EMPLOYERS AND CORPORATIONS)
ARE YOU LIABLE FOR FEDERAL UNEMPLOYMENT TAX?
YES
NO
IF YES WHAT WAS THE FIRST YEAR OF LIABILITY: ________________________________
DO YOU HAVE AN IRS WRITING THAT GRANTS AN EXCLUSION FROM FEDERAL UNEMPLOYMENT TAX?
YES (Attach copy)
NO
IV. IDENTIFICATION OF OWNER (AND SPOUSE IF MARRIED) PARTNERS, CORPORATE OFFICERS, MEMBERS AND/OR
MANAGING MEMBERS OR OFFICIALS OF THIS EMPLOYING UNIT
If the owner, partners, corporate offi cers or combination of partners or corporate offi cers, members and/or managing members own or control more than 50% of another
business in Arizona, attach a list of the businesses, percentages owned and unemployment insurance account numbers.
NAME (Last, First, M.I.)
SOC. SEC. NO.
TITLE
% OWNED
COMPLETE RESIDENCE ADDRESS
PHONE NUMBER
(
)
(
)
(
)
(
)
DO YOU HAVE OR HAVE YOU PREVIOUSLY HAD AN ARIZONA STATE TAX NUMBER? YES
NO
IF YES, FILL IN BELOW AND CHECK HERE IF YOU WANT TO CANCEL THE EXISTING NUMBER
BUSINESS NAME
UNEMPLOYMENT NO.
WITHHOLDING NO.
TPT NO.
THIS APPLICATION MUST BE COMPLETED, SIGNED AND RETURNED AS PROVIDED BY ARS § 23-722
Equal Opportunity Employer/Program • This document available in alternative formats by contacting the UI Tax Offi ce.
ADOR 74-4002 (3/03)
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