Form 21-006e - Questionnaire 21-006 Service Activies In Iowa For A Corporation, Partnership Or Llc Page 5

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Page 5
19. Please provide the names, addresses, titles and telephone numbers of all employees who helped complete
this questionnaire or provided information for the questionnaire.
I declare that the information furnished in response to this questionnaire is to the best of my knowledge and
belief, true, correct, and complete:
____________________________________________
Date
____________________________________________
Signature of Corporate Officer, Partner or Owner
____________________________________________
Title of Corporate Officer, Partner or Owner
____________________________________________
Preparer’s Name (print or type)
____________________________________________
Preparer’s Title (print or type)
____________________________________________
Preparer’s Signature
____________________________________________
Preparer’s Phone Number
Mail the completed questionnaire to:
Iowa Department of Revenue
Examination Section/Compliance Division
PO Box 10456
Des Moines, IA 50306-0456
21-006e(03/28/11)

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