Form Tp-650 - Application For Registration Under Articles 12-A And 13-A (Page 2 of 4) in pdf

Page 2 of 4 TP-650 (12/13)

12a List owner(s), officers, directors, partners, and responsible employees

. Attach additional sheets if necessary.

(see instructions)

Social security number (SSN) or EIN Type(s) of registration(s) (a‑j)

Name

(see instr.)

Home address

Percentage of ownership

Title

(number and street)

City

State

ZIP code

Duties (a‑g)

Telephone number

(see instructions)

(

)

SSN or EIN

Name

Type(s) of registration(s) (a‑j)

(see instr.)

Home address

Percentage of ownership

Title

(number and street)

City

State

ZIP code

Duties (a‑g)

Telephone number

(see instructions)

(

)

SSN or EIN

Name

Type(s) of registration(s) (a‑j)

(see instr.)

Home address

Percentage of ownership

Title

(number and street)

City

State

ZIP code

Duties (a‑g)

Telephone number

(see instructions)

(

)

12b For a corporation only, enter the total percentage of voting stock held by all shareholders

(the percentage of voting stock in lines 12a and 12b

..........................................................................................................................................................................

must total 100%; see instructions)

13 During the last five years, has the applicant or any person listed in line 12a:

•

owned or controlled, directly or indirectly, more than 10% (25% or more if there are four or fewer shareholders) of the voting stock of a business other

than the applicant, or

•

been an employee of a business (other than the applicant) who was under a duty to file a return or pay taxes under Articles 12-A or 13-A on behalf of

such business, or

•

been an officer, director, or partner of a business other than the applicant?

Yes

If Yes, complete below

(see instructions; attach additional sheets if necessary)

EIN

Name of other business

Address

City

State

ZIP code

(number and street)

Name of person or applicant

Inclusive dates

EIN

Name of other business

Address

City

State

ZIP code

(number and street)

Name of person or applicant

Inclusive dates

14 In the past five years, was any person listed in line 12a convicted of any crime, or was any person listed in line 12a associated with a business (as

described in line 13) at the time the business was convicted of any crime

(see instructions)

Yes

If Yes, complete below

(see instructions; attach additional sheets if necessary)

Name of person

Name of business

City and state of arrest

(if applicable)

Statute section convicted of violating Disposition (fine, imprisonment, etc.)

Date of conviction

Court of conviction