Form Cg-100-P - Personal Questionnaire (Page 4 of 4) in pdf

Page 4 of 4 CG-100-P (3/06)

19.

Indicate your contribution to the applicant. Include cash, real estate, customer lists, promissory notes, inventories, and any other

tangible or intangible assets.

Amount

Source of funds. If a current bank or brokerage account, give account

number; for gifts or loans, identify source; if proceeds from the sale of assets,

Contribution

value

identify specific assets.

Cash

Real estate

Inventory

Customer lists

Tangible assets

Intangible assets

Other

If you are guaranteeing a loan as a

Amount

Identify loan and describe the collateral

cosigner or by pledging collateral

value

(identify each such transaction below)

Cosigner

Collateral

Cosigner

Collateral

20. For purposes of this application the term controlling person means any person who is an officer, director, or, partner (or, in the case of a

limited liability company, an officer, member or a person having, with respect to such limited liability company, authority analogous to that of

an officer or director with respect to a corporation) of an applicant for an agent’s or wholesale dealer’s license under Article 20 of the Tax Law,

or if the applicant is a corporation, a shareholder, directly or indirectly, owning more than 10% of the number of share of voting stock of such

corporation. It also includes persons who do or will exercise authority within the business comparable to the authority normally exercised by

corporate officers, regardless of the form of business organization or lack of actual title.

I understand that the information I submit herein will be relied upon by the New York State Department of Taxation and Finance and a

false statement or misrepresentation may constitute cause for the disapproval of the application or revocation of any license for which this

application is submitted. I affirm that statements made herein are true and if any change occurs prior to the receipt of the license, I will notify

the NYS Department of Taxation and Finance at the address shown on page 1 of this form by registered or certified mail within 48 hours. If a

change occurs after receipt of the license, I understand that I must advise the Department prior to the occurrence of any change of ownership

and/or location. The Department must be notified within 10 days of all other changes.

Signature

Title

Date

Privacy notification

The Commissioner of Taxation and Finance may collect and maintain personal information pursuant to the New York State Tax Law, including but not

limited to, sections 171, 171-a, 287, 308, 429, 475, 505, 697, 1096, 1142, and 1415 of that Law; and may require disclosure of social security numbers

pursuant to 42 USC 405(c)(2)(C)(i).

This information will be used to determine and administer tax liabilities and, when authorized by law, for certain tax offset and exchange of tax

information programs as well as for any other lawful purpose.

Information concerning quarterly wages paid to employees is provided to certain state agencies for purposes of fraud prevention, support

enforcement, evaluation of the effectiveness of certain employment and training programs and other purposes authorized by law.

Failure to provide the required information may subject you to civil or criminal penalties, or both, under the Tax Law.

This information is maintained by the Director of the Registration and Data Services Bureau, NYS Tax Department, Building 8, Room 338,

W A Harriman Campus, Albany NY 12227; telephone 1 800 225-5829. From areas outside the United States and Canada, call (518) 485-6800.

Form Cg-100-P - Personal Questionnaire Page 4

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