Form Reg-7 - Application For Authority To Collect Connecticut Use Tax Page 2
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25. List All Owners, Partners, Corporate Offi cers, or LLC Members.
Attach a separate sheet if needed.
Name (Last, First, Middle Initial)
Title
Home Address Line 1 (Street)
Home Address Line 2
City
State
ZIP Code
Home Telephone Number
(
)
Social Security Number (SSN)
Date of Birth
Bank Name
/
/
Name (Last, First, Middle Initial)
Title
Home Address Line 1 (Street)
Home Address Line 2
City
State
ZIP Code
Home Telephone Number
(
)
SSN
Date of Birth
Bank Name
/
/
Name (Last, First, Middle Initial)
Title
Home Address Line 1 (Street)
Home Address Line 2
City
State
ZIP Code
Home Telephone Number
(
)
SSN
Date of Birth
Bank Name
/
/
6. All Applicants Must Sign the Following Declaration
I declare under penalty of law that I have examined this application (including any accompanying schedules and statements) and, to the
best of my knowledge and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false return or document
to the Department of Revenue Services (DRS) is a fi ne of not more than $5,000, or imprisonment for not more than fi ve years, or both.
Signature of Owner, Partner, LLC Member, or Corporate Offi cer
Date
Telephone Number
Sign Here
(
)
Keep a copy
for your
Print Name of Owner, Partner, LLC Member, or Corporate Offi cer
Title
records.
Purpose: Out-of-state retailers not engaged in business in
Nature of Business Activity: Check the box(es) that best
Connecticut use REG-7 to register with DRS for the authority to
describe your business.
collect use tax on their sales of goods to be used in Connecticut.
Major Business Activity: Describe fully the activities of
this business, particularly its sales activities connected with
Business Name and Address: Enter the exact legal name of
Connecticut.
business for which this application is being completed. If the
business entity is a sole proprietorship or partnership, enter the
Owners, Partners, Corporate Offi cers, or LLC Members:
legal name or names of the owners.
Enter the name, title, home address, home telephone number,
SSN, date of birth, and bank name of all owners, partners,
Enter the FEIN assigned to this business. Sole proprietors not
corporate offi cers, or LLC members. If you require additional lines,
assigned a FEIN, leave this box blank.
create an identical schedule and attach it to the application.
Enter the trade name of this business if different from the legal
Declaration: An owner, partner, LLC member, or corporate
name of the business entity. If it is not different, enter “same as
offi cer must sign the application.
above.”
Mail the Application to: Department of Revenue Services
Enter the physical location, email address, and telephone number
State of Connecticut
of this business. Do not enter a PO Box number.
PO Box 2937
Enter the name of the bank the organization does business with.
Hartford CT 06106
If the application is approved, DRS issues a confi rmation notice,
Enter the business mailing address if different from physical
a personal identification number (PIN), and a certificate of
location. If it is not different, enter “same as above.”
authority to collect Connecticut use tax.
Business Information: Check the appropriate box to indicate
For more information visit the DRS website at
the type of organization of the business. If this business is
or call 1-800-382-9463 (Connecticut calls outside the Greater
incorporated, enter the state in which it is incorporated.
Hartford calling area only) or 860-297-5962 (from anywhere).
REG-7 Back (Rev. 08/08)
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