Form Cg-100-P - Personal Questionnaire
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4CG-100-P
New York State Department of Taxation and Finance
Personal Questionnaire
(3/06)
Article 20 of the Tax Law
Notice to individuals completing this form:
You may return the completed form to the NYS Department of Taxation and Finance in either of two ways:
– by giving it to the applicant for inclusion with the license application form; or
– by mailing directly to the Department at the following address:
NEW YORK STATE TAX DEPARTMENT
TTTB - REGISTRATION AND BOND UNIT
WA HARRIMAN CAMPUS
ALBANY NY 12227
Please print or type.
Answer all questions. Indicate N/A if not applicable. If more space is needed, attach additional pages, clearly indicating the question to which the answer
applies. Unanswered questions will delay the processing of this application.
1.
Legal name of applicant for license
Federal employer identification number (FEIN)
2.
Your name
Social security number
Date of birth
Home telephone number
(
)
Home address
Street
City
State
ZIP code
Years at this address
3.
If less than 10 years at current home address, please list former addresses for the past 10 years.
Street
City
State
ZIP code
From (mo./yr.)
To (mo./yr.)
4. (a) Title/position or relationship to applicant
(b) Briefly describe your role and authority within the applicant’s business.
(c) Check appropriate box(es) for each authority you do or will have.
Signing checks on the company’s bank account
Conducting the business’ general financial affairs
Signing the business’ tax returns
Filing returns or paying taxes imposed
Paying creditors
Complying with any other requirement of the Tax Law
Making the final decision on which bills are to be paid
Ordering, receiving, or picking up cigarette stamps
Other
5.
Have you ever been known by any other name(s)?
Yes If Yes, State each name (including maiden name), social security number, and dates used.
No
6. Height
Weight
Sex
Eye color
Hair color
Married
Country of birth U.S. Citizen
Yes
No
(ft./in.)
(lbs.)
(circle one)
(circle one)
(If No, state registration number or visa type)
yes / no
F
M
Attach additional sheets as needed. Please include the item number referenced on additional sheets.
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Parent category: Financial