Form Cr-16 - Kansas Business Tax Application - 2017 Page 4
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ENTER YOUR EIN: ____________________________________
SSN: __________________________________
PART 12
– OWNERSHIP DISCLOSURE AND SIGNATURE STATEMENT
List ALL owners, partners, corporate officers and directors. Provide the personal information and signatures of all persons who have
control or authority over how business funds or assets are spent. If more space is needed, attach additional pages.
Certification: To the best of my knowledge and belief the information on this application is true, correct, and complete. If the business fails
to report or pay appropriate state taxes, any individual who is responsible for the tax authorizes the Secretary of Revenue or his/her designee
to research the credit history of the business or that individual.
X
__________________________________________________________________________
_____________________________________________________________
Printed full proper name of owner, partner or corporate officer
Signature of owner, partner or corporate officer
Date
SSN: ____________________________________________________________________
Title: ___________________________________________________________
Home address: ___________________________________________________________
________________________________________________________________
City
State
Zip Code
Home phone: ___________________________________ Email: ___________________________________________________ Percent of Ownership: ________ %
Yes
No
Do you have control or authority over how business funds or assets are spent?
_________________________
Date that you became the owner, partner or corporate officer of this business:
_______________________________________________________________________
X
_________________________________________________________________________
_
____________________________________________________________
Printed full proper name of owner, partner or corporate officer
Signature of owner, partner or corporate officer
Date
SSN: ____________________________________________________________________
Title: ___________________________________________________________
Home address: ___________________________________________________________
________________________________________________________________
City
State
Zip Code
Home phone: ___________________________________ Email: ___________________________________________________ Percent of Ownership: ________ %
Yes
No
Do you have control or authority over how business funds or assets are spent?
_________________________
Date that you became the owner, partner or corporate officer of this business:
_______________________________________________________________________
X
__________________________________________________________________________
_____________________________________________________________
Printed full proper name of owner, partner or corporate officer
Signature of owner, partner or corporate officer
Date
SSN: ____________________________________________________________________
Title: ___________________________________________________________
Home address: ___________________________________________________________
________________________________________________________________
City
State
Zip Code
Home phone: ___________________________________ Email: ___________________________________________________ Percent of Ownership: ________ %
Do you have control or authority over how business funds or assets are spent?
Yes
No
_________________________
Date that you became the owner, partner or corporate officer of this business:
_______________________________________________________________________
X
__________________________________________________________________________
_____________________________________________________________
Printed full proper name of owner, partner or corporate officer
Signature of owner, partner or corporate officer
Date
SSN: ____________________________________________________________________
Title: ___________________________________________________________
Home address: ___________________________________________________________
________________________________________________________________
City
State
Zip Code
Home phone: ___________________________________ Email: ___________________________________________________ Percent of Ownership: ________ %
Yes
No
Do you have control or authority over how business funds or assets are spent?
_________________________
Date that you became the owner, partner or corporate officer of this business:
Send this form and any payments to: KANSAS DEPARTMENT OF REVENUE, 915 SW HARRISON ST ., TOPEKA KS 66612-1588 or FAX to 785-291-3614 .
For assistance call 785-368-8222 .
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