Form Reg-1 - Application For Tax Registration Number - 2017

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APPLICATION FOR TAX REGISTRATION NUMBER
STATE OF CONNECTICUT
DEPARTMENT OF REVENUE SERVICES
REG-1
DO NOT WRITE IN THIS BLOCK
25 Sigourney Street
IMPORTANT!
PO Box 2937
Hartford CT 06104-2937
READ INSTRUCTIONS ON REVERSE
BEFORE COMPLETING THIS APPLICATION
(Rev 5/2000)
PRINT CLEARLY IN INK OR TYPE ALL INFORMATION REQUESTED
1.
REASON FOR APPLYING:
STARTED NEW
PURCHASED GOING BUSINESS
REGISTERING FOR ADDITIONAL TAXES
OTHER
DRS USE ONLY
(Explain on reverse)
BUSINESS
(Furnish Name & CT Tax Registration
(Explain
Number of previous owner on reverse)
on reverse)
REC
AD
2.
OWNER’S NAME, ALL PARTNERS’ NAMES, LLC NAME OR CORPORATE NAME:
3. FEDERAL EMPLOYER I.D. NO.
4.
TRADE OR REGISTERED NAME IF DIFFERENT FROM ABOVE:
5. TELEPHONE NUMBER
(
)
1 2 3 4 5
1 2 3 4 5
6.
PHYSICAL LOCATION OF THIS BUSINESS: (P.O. Box is not acceptable)
1 2 3 4 5
(ZIP + 4)
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
7.
BUSINESS MAIL ADDRESS:
(ZIP + 4)
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
8.
NAME OF:
OWNER
PARTNER
CORPORATE OFFICER
LLC MEMBER
DATE OF BIRTH
9. SOCIAL SECURITY NUMBER
Mo.
Day
Yr.
1 2 3 4 5
1 2 3 4 5
HOME ADDRESS Number and Street
10. TELEPHONE NUMBER
City or Town
State
(ZIP + 4)
1 2 3 4 5
1 2 3 4 5
(
)
1 2 3 4 5
11.
NAME OF:
PARTNER
CORPORATE OFFICER
LLC MEMBER
DATE OF BIRTH
12. SOCIAL SECURITY NUMBER
Mo.
Day
Yr.
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
HOME ADDRESS Number and Street
City or Town
State
13. TELEPHONE NUMBER
(ZIP + 4)
1 2 3 4 5
(
)
1 2 3 4 5
1 2 3 4 5
14.
NAME OF:
PARTNER
CORPORATE OFFICER
LLC MEMBER
DATE OF BIRTH
15. SOCIAL SECURITY NUMBER
Mo.
Day
Yr.
1 2 3 4 5
1 2 3 4 5
State
1 2 3 4 5
HOME ADDRESS Number and Street
City or Town
16. TELEPHONE NUMBER
(ZIP + 4)
1 2 3 4 5
1 2 3 4 5
(
)
1 2 3 4 5
17.
DESCRIBE IN DETAIL THE TYPE OF BUSINESS YOU OPERATE:
18. NAME OF BANK (BRANCH) BUSINESS WILL USE:
20.
DATE BUSINESS STARTED IN CONNECTICUT
19.
TYPE OF ORGANIZATION:
CORP.
S CORP.
SOLE PROPRIETOR
PARTNERSHIP
Mo.
Day
Yr
.
AT THIS PHYSICAL LOCATION UNDER
OTHER
LLC TAXED AS a.)
PARTNERSHIP
b.)
CORP.
THIS OWNERSHIP:
22.
DO YOU HOLD A VALID CONNECTICUT SALES
21.
IS YOUR BUSINESS:
WHOLE-
MANUFAC-
TAX PERMIT FOR ANY OTHER LOCATION?
YES
NO
TURER
RETAIL
SALE
SERVICES
OTHER
(if Yes, list locations on reverse)
23A. WILL YOUR PAYROLL REQUIRE CT STATE WITHHOLDING?
Mo.
Day
Yr.
23B. WILL THIS BUSINESS LOCATION REPORT WITHHOLDING TAXES INDEPENDENTLY?
YES
NO
IF YES, ENTER START DATE:
NO
IF NO,
LIST LOCATION ON REVERSE SIDE.
YES
24.
IF YOU ARE REGISTERING FOR ADMISSIONS, DUES AND CABARET TAX , CHECK
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
ALL YEAR
THE APPROPRIATE BOXES AND INDICATE WHICH MONTHS YOUR BUSINESS IS ACTIVE.
ONE TIME
ADMISSIONS
DUES
IF YOU ARE NOT INCORPORATED, PLEASE GO DIRECTLY TO LINE 30
25.
WHAT IS THE CLOSING DATE
Day 26.
ORGANIZED
27.
IF OTHER THAN CT CORPORATION,
Mo.
Day
Yr
Mo.
.
OF YOUR CORPORATE
UNDER LAWS
SHOW DATE REGISTERED WITH CT
SECRETARY OF STATE
OF WHAT STATE?
INCOME YEAR?
28.
DATE OF
Mo. Day Yr.
29. DO YOU HAVE A FEDERAL CORPORATE INCOME TAX EXEMPTION?
YES
NO
INCORPORATION
IF YES: Enclose a copy of IRS Letter of Exemption in order to qualify in Connecticut.
YES
NO
Do you have unrelated business taxable income from carrying on an unrelated trade or business?
$
30. Do you intend to sell cigarettes over the counter as a dealer?
YES
NO
If Yes, enter $25 at right.
31. Do you rent/lease passenger motor vehicles for 30 days or less?
(See General Instructions on reverse)
NO
YES
YES
NO
32. DRS use only
33. Do you operate a dry cleaning establishment?
34. Do you intend to engage in:
SALES OF GOODS
LEASING AND/OR RENTAL OF TANGIBLE PERSONAL PROPERTY TO OTHERS
RENTING ROOMS FOR 30 DAYS OR LESS
SALES OF TAXABLE SERVICES
$
If you have checked one or more of the above boxes, enter $20 at righ
t
35. Are you liable for Business Use Tax?
(See General Instructions on reverse)
YES
NO
$
0
36.
TOTAL AMOUNT DUE (Add Line 30 and Line 34)
(Make check payable to: COMMISSIONER OF REVENUE SERVICES)
Signature of
Owner, Partner
TITLE:
DATE:
or Corporate Officer X X X X X
DO NOT WRITE BELOW THIS LINE - FOR DEPARTMENT USE ONLY
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
LEGAL DATE
TAX TYP.
TRANS
REGIST. DATE
S.I.C. CODE
TYPE OF ORG.
STATE
TOTAL SUBMITTED
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
00
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9
TAX TYP.
TRANS
REGIST. DATE
START DATE
BUS. TOWN
SRCE.
LIAB.
TYP FIL
MAIL
SECURITY NO.
SECURITY AMOUNT
FEE REMITTED
FILING CODE
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
TAX TYP.
TRANS
REGIST. DATE
START DATE
BUS. TOWN
SRCE.
FL.CD.
PENALTY REMIT.
TOTAL REMITTED
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
63
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4
TAX TYP.
TRANS
REGIST. DATE
START DATE
BUS. TOWN
SRCE
LIAB.
FL.CD.
TY FL.
MAIL
FISCAL YR.
SECURITY NO.
SECURITY DATE
SECURITY AMOUNT
1 2 3 4 5 6 7 8 9 0 1 2 3
1 2 3 4 5 6 7 8 9 0 1 2 3
TAX TYP.
TRANS
REGIST. DATE
START DATE
BUS. TOWN
SRCE.
LIAB.
FL.CD.
SECURITY NO.
SECURITY DATE
SECURITY AMOUNT
1 2 3 4 5 6 7 8 9 0 1 2 3
30
1 2 3 4 5 6 7 8 9 0 1 2 3
1 2 3 4 5 6 7 8 9 0 1 2 3
TAX TYP.
TRANS
REGIST. DATE
START DATE
BUS. TOWN
SRCE.
FILING
PAY SCHED.
TYP FIL
MAIL
PCC
SECURITY NUMBER
SECURITY AMOUNT

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