Form Ador 74-4002 - Arizona Joint Tax Application Page 2
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4UC-001 (3/03) - REVERSE (Page 2)
DES
THIS BOX FOR AGENCY USE ONLY
DOR
TPT__________________________________________________
NEW
CHANGE
REVISE
REOPEN
ACCT NO___________________________LIAB______________________________
W H__________________________________________________
START________________________LIAB EST DATE__________________________
CITIES _________ _________ _________ _________ _________
S/E DATE
V. LOCATION OF TAX RECORDS (by whom and where your records are maintained)
NAME OF COMPANY OR PERSON TO CONTACT
PHONE NUMBER
(
)
(Street, City, State and Zip) (Do not use P.O. Box or Route No.)
ADDRESS
VI. ADDITIONAL INFORMATION
What is your anticipated annual income for your fi rst twelve months of business?
Does your business sell new motor vehicle tires or vehicles?
Yes
No
Does your business sell tobacco products?
Yes
No
Retailer
Distributor
Did you acquire all or part of an existing business?
Yes
No
If yes, you must complete Unemployment Tax Addendum, Page 3.
VII. EMPLOYMENT INFORMATION (complete only if applying for withholding/unemployment tax license)
Record of Arizona wages paid by calendar quarters for current and preceding calendar years.
YEAR
1ST QUARTER
2ND QUARTER
3RD QUARTER
4TH QUARTER
Weekly record of number of persons performing services in Arizona for current & preceding calendar year.
YEAR
JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
VIII. ARE INDIVIDUALS PERFORMING SERVICES FOR YOU EXCLUDED FROM WITHHOLDING OR UNEMPLOYMENT TAX?
Yes
No
If yes, explain:
IX. FEES FOR TRANSACTION PRIVILEGE TAX (no fee for withholding, use or unemployment)
State Fees (# loc. x $12.00):
City Fees (Total from Table):
Total Fees:
X. SIGNATURE(S) BY INDIVIDUALS LEGALLY RESPONSIBLE FOR THE BUSINESS (REQUIRED)
This application must be signed by either a sole owner, two partners, two corporate offi cers, members and/or managing members, the trustee,
receiver or personal representative of an estate.
UNDER PENALTY OF PERJURY I (WE) DECLARE THAT THE INFORMATION ON THIS DOCUMENT IS TRUE AND CORRECT.
TYPE OR PRINT NAME
TITLE
SIGNATURE
DATE
TYPE OR PRINT NAME
TITLE
SIGNATURE
DATE
ADOR 74-4002 (3/03)
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