Form Cd-3 - Application For Meals & Rentals Tax Operators License & Ach Debit Authorization

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FORM
NEW HAMPSHIRE DEPARTMENT OF REVENUE ADMINISTRATION
CD-3
APPLICATION FOR MEALS & RENTALS TAX
55
OPERATORS LICENSE & ACH DEBIT AUTHORIZATION
FOR DRA USE ONLY
LICENSE REQUIRED BEFORE OPERATING
License Number
Date Issued
Be sure to read instructions on reverse side before filling out this form.
PLEASE TYPE OR PRINT CLEARLY
1
BUSINESS NAME
2
NAME OF ENTITY
3
STREET ADDRESS
4
ADDRESS CONTINUED
5
CITY OR TOWN
STATE
ZIP CODE
Type of Legal Organization
Proprietorship
Corporation
Partnership
Fiduciary
Non-Profit
6a
1
4
5
2
3
6b
LLC Taxed as
Single Member
Corporation
Partnership Complete EITHER 6a or 6b, but not both
3
1
2
(Do Not Enter SSN)
7
Federal Employer Identification Number of the above operation:
If you have not entered an FEIN at line 7 above, under what social security number or department identification number will your business taxes for
8
this operation be filed? SSN:
or DIN:
N L
9
List individual owner, partners or president and treasurer:
Name
Title
Social Security Number
Home Address
STREET ADDRESS
CITY/TOWN, STATE, ZIP CODE
STREET ADDRESS
CITY/TOWN, STATE, ZIP CODE
STREET ADDRESS
CITY/TOWN, STATE, ZIP CODE
10
Contact Person if other than above
Telephone # (
)
Ext.
NAME
TITLE
11
Business Telephone # (
)
Ext.
Home Telephone # (
)
12
Business Location in NH
STREET, CITY and ZIP CODE
13
Proposed opening date
/
/
(Required)
14
Type of business activity
15
Check Here if you Serve....
Food
Alcoholic Beverages
16
Check here if you rent........
Sleeping Accommodations. Number of Rooms
Function Rooms
17
Check here if you are requesting permission to file returns on a seasonal basis (less than twelve returns per year).
If yes what months will the business operate?
18
Prior business name
Prior Owner
I hereby certify that the above given information is true and correct and in conformity with applicable state laws.
SIGNATURE (IN INK) (REQUIRED ON ALL APPLICATIONS)
TITLE
DATE
ACH DEBIT AUTHORIZATION
20 Bank Routing
Bank
19
& Transit #
Name
FOR DRA USE ONLY
Name on
FEIN/SSN on
22
21
Bank Account
Bank Account
Bank
Account Type
Statement Savings
Checking
24
23
Account
(check one)
Number
YOU MUST PROVIDE A COPY OF A VOIDED CHECK OR A SAVING WITHDRAWAL SLIP FOR THIS ACCOUNT.
By signing below, I hereby authorize the New Hampshire Department of Revenue to initiate variable debit entries to the bank account
and the depository named above.
Signature(in ink) (required for all ACH Debit Authorizations)
Title
Date
Mail To:
Collections Division, PO Box 454, Concord, NH 03302-0454. Telephone No. (603) 271-3701.
(12)
Form CD-3
Rev. 10/03

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