Contractor'S Request For Clearance - North Dakota Tax Commissioner
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1Office of State Tax Commissioner
Sales and Special Taxes Division
600 E. Boulevard Ave., Dept. 127
Bismarck, North Dakota 58505-0599
CONTRACTOR’S REQUEST FOR CLEARANCE
Pursuant to North Dakota Century Code § 43-07-11.1, as amended, a request for Income, Sales and Use Tax Clearance
is made on behalf of:
Corporate, Legal, or Owner’s Name ________________________________________________________________________________________________
Business Name ________________________________________________________________________________________________________________
Business Address _________________________________________________________
Phone # ___________________________________________
Mailing Address _______________________________________________________________________________________________________________
Please Complete the following:
Resident [ ]
Nonresident [ ]
North Dakota Contractors License No. _________________________________
North Dakota Sales & Use Tax Permit No. ______________________________
Type of Ownership
____ Sole Ownership
Social Security No. ________________________________________________
____ General Partnership
Federal ID No. ____________________________________________________
____ Corporation
N.D. Income Tax Returns Filed for 2004 ___ 2003 ___ 2002 ___ 2001 ___
____ S Corporation
North Dakota Return Filed under Federal ID No. _________________________
____ Limited Partnership
If incorporated, Date of Incorporation _________________________________
____ Limited Liability Company
Registered for North Dakota Income Tax Withholding
Yes _____ No _____
Other (Specify) _______________________
If not, please explain: _____________________________________________
____________________________________
Description of business (list all types of activity) _________________________
________________________________________________________________
Has business activity been conducted in North Dakota anytime during the past
three years?
Yes _____ No _____
The application must be signed. If a sole ownership, by Owner; if a partnership, by Each Partner; if a corporation, by a Corporate
Offi cer having the responsibility for fi ling reports, or if a limited liability company, by a Governor or Manager.
________________________________________________________________________________________________________
Printed Name
Signature
Title
S.S. #
Date
________________________________________________________________________________________________________
Printed Name
Signature
Title
S.S. #
Date
________________________________________________________________________________________________________
Printed Name
Signature
Title
S.S. #
Date
________________________________________________________________________________________________________
Printed Name
Signature
Title
S.S. #
Date
Please complete and forward one copy of this form to the Offi ce of State Tax Commissioner. A clearance certifi cate will be issued
to the contractor, provided the contractor has paid all income and sales or use taxes
It will be the contractor’s duty to furnish the
Date: ___________________________________________
necessary proof of clearance to governmental
entities and other interested parties. This can
be done by forwarding a copy of their clear-
CLN
___________________________________________
ance certifi cate to the appropriate entities or
persons.
FOR OFFICE USE ONLY
21884
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