California Form 3565 Draft - Small Business Stock Questionnaire - 2009 Page 2
ADVERTISEMENT
1
2
3CALIFORNIA FORM
TAXABLE YEAR
2009
3565
Small Business Stock Questionnaire
Attach to Form 100 or Form 100W.
Corporation name
California corporation number
-
Address (suite, room, or PMB no.)
FEIN
City
State ZIP Code
A. Taxable year (beginning and ending)
B. Date of incorporation
C. State of incorporation
D. Date of qualification in California
E. Principal business activity
F. Principal business activity code (Do not leave blank)
If the answer to any of the questions G through L is “No,” STOP; do not complete this form because the stock issuance does not qualify
under California Revenue and Taxation Code Section 18152.5.
G. Did the corporation issue non-treasury stock during the current taxable year? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
Date of stock issuance for which this information applies:
/
/
Month
Day
Year
H. Was the non-treasury stock issued, in whole or in part, for money, for property other than stock, or for services
provided to the corporation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
I.
Were the corporation’s aggregate gross assets less than or equal to $50,000,000 from the period beginning
July 1, 1993, to the date of issuance of the non-treasury stock? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
J.
Was at least 80% of the corporation’s payroll in California at the date of issuance of the non-treasury stock? . . . . . . . . . Yes
No
K. Was the corporation a domestic corporation at the date of issuance of the non-treasury stock? . . . . . . . . . . . . . . . . . . . . Yes
No
L.
Since the issuance of non-treasury stock, was this a corporation with a classification other than a:
• Regulated Investment Company (RIC), Real Estate Investment Trust (REIT), or
Real Estate Mortgage Investment Conduit (REMIC)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
• Domestic International Sale Corporation (DISC) or former DISC? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
• Corporation with an IRC Section 936 election in effect or a direct or indirect subsidiary with an election? . . . . . . . . . . Yes
No
• Cooperative? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
M. Did the corporation’s assets (in excess of liabilities) consist of 10% or less of stocks or securities of a
non-subsidiary corporation(s)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes
No
N. Since the issuance of non-treasury stock, was this corporation a C corporation for California purposes? . . . . . . . . . . . . . Yes
No
O. Since the issuance of non-treasury stock, were at least 80% (by value) of the corporation’s assets used in
the active conduct of one or more qualified trades or businesses in California? See instructions . . . . . . . . . . . . . . . . . . . . Yes
No
P.
What percentage of the total value of assets consisted of real property not used in the active conduct
of the trade or business? See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
__________%
Q. What was the aggregate subscription amount for all non-treasury stock issuances during the corporation’s
existence prior to the current issuance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _____________
R. What was the aggregate subscription amount of non-treasury stock issued during the current taxable year? . . . . . . . . . . $ _____________
S. How much of the amount in Question R did the corporation receive for qualified small business stock? . . . . . . . . . . . . . $ _____________
T.
What was the date of the first non-treasury stock issuance during the current taxable year? . . . . . . . .
/
/
Month
Day
Year
U. What was the date of the last non-treasury stock issuance during the current taxable year? . . . . . . . .
/
/
Month
Day
Year
V.
What was the aggregate percentage of the total purchases of this corporation’s own stock (relative to the aggregate
value of the corporation’s total stock for a two-year period beginning on the date one year before the issuance of
this stock)? (If the aggregate percentage is more than 5%, the stock does not qualify as small business stock .) . . . . . . .
__________%
Under penalties of perjury, I declare that I have examined this form, and to the best of my knowledge and belief, it is true, correct, and complete.
Signature
of officer
Date
Print name and title
FTB 3565
2009
7401093
C3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial