Form Boe-404-A - Qualified Purchaser Use Tax Registration - California Board Of Equalization

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BOE-404-A REV. 5 (8-11)
STATE OF CALIFORNIA
QUALIFIED PURCHASER USE TAX REGISTRATION
BOARD OF EQUALIZATION
INSTRUCTIONS
(PLEASE READ BEFORE COMPLETING THIS FORM)
Who is NOT required to register as a “qualified purchaser”?
You are not required to register or fill out this form if:
 You have an active seller’s permit with the State Board of Equalization (BOE) or
 Your business has never received more than $100,000 in gross receipts from business operations in any calendar year
Who IS required to register as a “qualified purchaser”?
If your business has ever received $100,000 or more in gross receipts from business operations in any calendar year you must:
 Register as a “qualified purchaser” with the
BOE
and
 Complete this registration form and return it to your nearest
BOE field office
For More Information
Please read the Qualified Purchaser Registration Requirements available on the
BOE
website.
OWNERSHIP INFORMATION
1. TYPE OF OWNERSHIP (check one)
Sole Owner
Corporation
General Partnership
Limited Partnership (LP)
Registered Domestic Partnership
Husband/Wife Co-Ownership
Limited Liability Partnership (LLP)
(Registered to practice law, accounting, or architecture)
Limited Liability Company (LLC)
Unincorporated Business Trust
Other (describe)
2. NAME OF SOLE OWNER, CORPORATION, LLC, PARTNERSHIP, OR TRUST
3. SIGNIFICANT ASSET/SUPPLY PURCHASES BEGAN (month, day, year)
4. BUSINESS TRADE NAME [DBA] (if any)
5. FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN)
6. CORPORATE, LLC, LLP OR LP NUMBER FROM CALIFORNIA SECRETARY OF STATE
OWNER/PARTNER/OFFICER INFORMATION
7. CHECK ONE:
Owner/Co-Owners
Partners
Corporate Officers
LLC Officers/Managers Members
Trustees/Beneficiaries
Registered Domestic Partners
Note: Use additional sheets to include information for more than two individuals.
8. FULL NAME (first, middle, last)
9. TITLE
10. SOCIAL SECURITY NUMBER (corporate officers excluded)
11. DRIVER LICENSE NUMBER
12. HOME ADDRESS (street, city, state, zip code)
13. HOME TELEPHONE NUMBER
(
)
14. FULL NAME (first, middle, last)
15. TITLE
16. SOCIAL SECURITY NUMBER (corporate officers excluded)
17. DRIVER LICENSE NUMBER
18. HOME ADDRESS (street, city, state, zip code)
19. HOME TELEPHONE NUMBER
(
)
BUSINESS CONTACT INFORMATION
20. NATURE OF BUSINESS (describe)
21. CALIFORNIA COUNTY BUSINESS LOCATION
22. CALIFORNIA BUSINESS ADDRESS (street, city, state, zip code) Do not list PO Box or mailing service.
23. BUSINESS TELEPHONE NUMBER
If you have more than one business location, please attach a list with addresses.
(
)
24. MAILING ADDRESS (street, city, state, zip code) Include this address if different from business address.
25. BUSINESS FAX NUMBER
(
)
26. NAME OF PRIMARY CONTACT (include title)
27. CONTACT
TELEPHONE NUMBER
(
)
28. BUSINESS EMAIL ADDRESS
29. BUSINESS WEB ADDRESS
30. Have you been contacted by BOE to register for a use tax account?
Yes
No
If yes, were you provided with a reference number?
Yes
No
If yes, what number?
NAME (typed or printed)
SIGNATURE
DATE
NAME (typed or printed)
SIGNATURE
DATE
31. Mail to: Your local BOE field office.
FOR BOE USE ONLY
TAX
IND
OFFICE
ACCOUNT NUMBER
NAICS CODE
BUSINESS CODE
A.C.C.
SU
34
PROCESSED BY
REPORTING BASIS
ACCOUNT ISSUE DATE
AREA CODE
Y
/
/
-999-000-0000
CLEAR
PRINT

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