Form Rev-203 Cm - Business Activities Questionnaire

Do you have an independent representative(s) performing any of the functions for you which are listed in number 3? . . . . . . . . . . . . . .

Yes

If yes, please provide a description of your relationship with this representative(s), and indicate when the representative(s) initiated the activity. State whether the

relationship is exclusive.

Are your business and the representative associated by an ownership interest? Explain.

OWNERSHIP OR LEASE OF PROPERTY LOCATED IN PENNSYLVANIA

STARTING DATE

ENDING DATE

Does or did the entity maintain an office or place of business in Pennsylvania . . . . . . . .

Yes

(1)

If yes, describe the nature of the business activities carried on at the office or place of business and its location.

Does or did the entity make use of any office or place of business of any subsidiary,

affiliate, or other entity located in Pennsylvania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

(2)

If yes, describe the nature of the business activities carried on at the office or place of business and its location.

Does or did the entity have inventories, including inventories on consignment, present in Pennsylvania?

(a) in public or private warehouse?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

(3a)

(b) on premises owned or rented? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

(3b)

Yes

(3c)

Are any of these Pennsylvania inventories delivered to destinations in Pennsylvania

pursuant to orders for sales of the entity's merchandise?. . . . . . . . . . . . . . . . . . . . . . . .

Yes

(4)

Does or did the entity own and/or lease, as lessor or lessee, any real or tangible

personal property, other than inventories in Pennsylvania? . . . . . . . . . . . . . . . . . . . . . .

Yes

(5)

If yes, indicate whether the entity was owner, lessor or lessee; describe the property and its uses by the entity in Pennsylvania; provide the dates the property

was first acquired for use in Pennsylvania and give its location.

Have you brought any equipment or tangible personal property into this state

used in conducting your business activity? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

(6)

D. AFFIRMATION (PLEASE PRINT)

I _________________________________________ , __________________________________________ , __________________________________________

(Name of Business Official)

(Title)

(Name of Business)

hereby affirm under penalties prescribed by law that this questionnaire has been examined by me and to the best of my knowledge and belief is true, correct and

complete. If prepared by a person other than taxpayer, statements are based on all information of which preparer has knowledge. The preparer also must com-

plete the information below.

Date

Signature of Owner/Officer/Partner

Social Security Number

Telephone Number

(

)

Date

Signature of Preparer

Name of Preparer

Telephone Number

(