California Form 3565 - Small Business Stock Questionnaire - 1999

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INCOME YEAR
CALIFORNIA FORM
1999
Small Business Stock Questionnaire
3565
Corporation name
California corporation number
Address
PMB no.
Federal employer identification no. (FEIN)
-
City
State
ZIP Code
A. Income year (beginning and ending)
B. Date of incorporation
C. State of incorporation
D. Date of qualification in California
E. Principal business activity
F. Principal business activity code (Do not leave blank)
If the answer to any of the following questions is NO, STOP, do not complete this form.
G. Did the corporation issue non-treasury stock during the current income year? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
/
/
Date of stock issuance for which this information applies:
Month
Day
Year
H. Was the non-treasury stock issued, in whole or in part, for money, for property other than stock, or for services
provided to the corporation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
I.
Were the corporation’s aggregate gross assets less than or equal to $50,000,000 from the period beginning
July 1, 1993 to the date of issuance of the non-treasury stock? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
J.
Did the corporation’s assets (in excess of liabilities) consist of 10% or less of stocks or securities of a
non-subsidiary corporation(s)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
K. Was at least 80% of the corporation’s payroll in California at the date of issuance of the non-treasury stock? . . . . . . .
Yes
No
L.
Was the corporation a domestic corporation at the date of issuance of the non-treasury stock? . . . . . . . . . . . . . . . . . .
Yes
No
M. Since the issuance of non-treasury stock, was this corporation a C corporation for California purposes? . . . . . . . . . . .
Yes
No
N. Since the issuance of non-treasury stock, was this a corporation other than a:
• RIC, REIT, or REMIC? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
• DISC or former DISC? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
• A corporation with an IRC Section 936 election in effect or a direct or indirect subsidiary with an election? . . . . . .
Yes
No
• A cooperative? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
O. Since the issuance of non-treasury stock, were at least 80% (by value) of the assets of the corporation used in
the active conduct of one or more qualified trades or businesses in California? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
P.
What was the aggregate subscription amount for all non-treasury stock issuances during the corporation’s
existence prior to the current issuance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ __________
Q. What was the aggregate subscription amount of non-treasury stock issued during the current income year? . . . . . . .
$ __________
R. Of the amount in Question Q, how much was received for qualified small business stock? . . . . . . . . . . . . . . . . . . . . .
$ __________
S. What was the date of the first non-treasury stock issuance during the current income year? . . . . .
/
/
Month
Day
Year
T.
What was the date of the last non-treasury stock issuance during the current income year? . . . . . .
/
/
Month
Day
Year
U. What was the aggregate percentage of the total purchases of this corporation’s own stock (relative to the aggregate
value of the corporation’s total stock for a two-year period beginning on the date one year before the issuance of
this stock)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
__________%
(If the aggregate percentage is more than 5%, the stock will not qualify as small business stock.)
Under penalties of perjury, I declare that I have examined this form, and to the best of my knowledge and belief, it is true, correct, and complete.
Print name and title
Date
Signature
of officer
356599109
FTB 3565
1999
C3

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