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8. If you are included in a consolidated Federal return, please provide the name, address and FEIN or TIN used
on that return:
9. Describe your business in detail (including copies of all sales brochures and other documents pertaining to
your products made available to your customers):
10. Enter name and Iowa mailing address for 5 largest customers located in Iowa:
(If you have no customers indicate this by stating “no Iowa customers”)
Name line 1 / Address line 2
Please Select One
End User
Reseller Other
a. 1. ____________________________________________
_______
______
______
2. ___________________________________________________________________________
b. 1. ___________________________________________
_______
______
______
2. ___________________________________________________________________________
c. 1. ___________________________________________
_______
______
______
2. ___________________________________________________________________________
d. 1. ___________________________________________
_______
______
______
2. ___________________________________________________________________________
e. 1. ___________________________________________
_______
______
______
2. ___________________________________________________________________________
11. Enter the requested information for the preceding three years for which tax information is available.
MM/DD/YY
IA Receipts
Total Receipts
Net Federal Taxable Income
Before Net Operating Loss
______________
_______________
______________
__________________
______________
_______________
______________
__________________
______________
_______________
______________
__________________
21-006b(03/28/11)