Form Cd-3 - Application For Meals & Rentals Tax Operators License & Renewal - New Hampshire Department Of Revenue
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FORM
NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
CD-3
APPLICATION FOR MEALS & RENTALS TAX
055
OPERATORS LICENSE & RENEWAL
LICENSE REQUIRED BEFORE OPERATING
License Number
New Application
Renewal License #
Date Issued
TYPE OR PRINT CLEARLY
1
BUSINESS / TRADE NAME (IF INDIVIDUAL, PRINT FIRST NAME, THEN LAST NAME)
SOS Business Registration #
NAME OF OWNER (IF INDIVIDUAL, PRINT LAST NAME, FIRST NAME; IF CORPORATION, PRINT CORPORATION NAME)
2
Filing Requirements
MAILING ADDRESS
3
$5.00 FEE
MAILING ADDRESS CONTINUED
4
CITY OR TOWN
5
STATE
ZIP CODE + 4
6(a)
Type of Business Entity:
1
Proprietorship
2
Corporation
3
Partnership
4
Fiduciary
5
Non-Profi t
6(b)
Is the Business Entity an LLC?
Yes
7
Federal Employer Identifi cation Number of the above business: FEIN:
(Do Not Enter SSN Here)
8
Federal Employer Identifi cation Number, Social Security Number or Department Identifi cation Number under which the business taxes for this entity
will be fi led FEIN/SSN:
or DIN:
N L
9
List all individual owners, partners, LLC members, managers, or corporate offi cers, as applicable:
9(a) PRINT NAME: FIRST, MI, LAST, SUFFIX
SOCIAL SECURITY NUMBER
RESIDENCE ADDRESS - NO PO BOXES
TITLE
TELEPHONE NUMBER
CITY/TOWN, STATE, ZIP CODE + 4
9(b) PRINT NAME: FIRST, MI, LAST, SUFFIX
SOCIAL SECURITY NUMBER
RESIDENCE ADDRESS - NO PO BOXES
TITLE
TELEPHONE NUMBER
CITY/TOWN, STATE, ZIP CODE + 4
9(c) PRINT NAME: FIRST, MI, LAST, SUFFIX
SOCIAL SECURITY NUMBER
RESIDENCE ADDRESS - NO PO BOXES
TITLE
TELEPHONE NUMBER
CITY/TOWN, STATE, ZIP CODE + 4
(FOR ADDITIONAL SPACE, CONTINUE ON PAGE 3)
PRINT NAME
TITLE
TELEPHONE NUMBER
10
Contact Person if other than above
BUSINESS TELEPHONE #
PHYSICAL BUSINESS ADDRESS IN NH (STREET ADDRESS, CITY, ZIP CODE)
11
12
PROPOSED OPENING DATE (REQUIRED FOR NEW APPLICATIONS)
TYPE OF BUSINESS ACTIVITY
13
14
15
Check here if you serve....
Food
Alcoholic Beverages
Number of Seats in Restaurant and/or Lounge
{
{
{
Sleeping Accommodations
Function Rooms
Motor
16
Check here if you rent.....
Vehicles
Number of Rooms
Seating Capacity
17
Check here
if you are requesting permission to fi le returns as a seasonal fi ler. Specify month(s):
PRIOR BUSINESS NAME
PRIOR OWNER(S) NAME
18(a)
18
NH BANKING INSTITUTION
NAME OF ACCOUNT HOLDER
19(a)
19
Complete pages 1, 2, and 3 and submit to the NH Department of Revenue Administration with the required application fee.
I hereby certify that the given information is true and correct and in conformity with applicable State laws. I am aware of my responsibility, as an
agent of the State in the collection and remittance of the Meals & Rentals Tax, to maintain records, as provided in RSA 78-A:19 and N.H. Code
of Admin. Rules, Rev. 706.01.
FOR DRA USE ONLY
$5.00 fee MUST accompany this application
x
Make checks payable to STATE OF NEW HAMPSHIRE
SIGNATURE (IN INK) OF OWNER/OPERATOR FROM LINE 9(a)
DATE
NH DRA
x
MAIL
COLLECTION DIVISION
TO:
PO BOX 454
SIGNATURE (IN INK) OF OWNER/OPERATOR FROM LINE 9(b)
DATE
CONCORD, NH 03302-0454
x
Form CD-3
SIGNATURE (IN INK) OF OWNER/OPERATOR FROM LINE 9(c)
DATE
Rev. 5/2010
1
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