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Form Ct-3-A/c - Report By A Corporation Included In A Combined Franchise Tax Return - 2014 Page 2

Page 2 of 2 CT-3-A/C (2014)

Designee’s name

Designee’s phone number

(print)

Third – party

Yes

(

)

designee

Designee’s e-mail address

(see instructions)

Certification: Under the penalties of perjury, I declare that this corporation is allowed to file on a combined basis under New York State

Law and is also liable for the group tax liability, and I certify that this report and any attachments are to the best of my knowledge and

belief true, correct, and complete.

Printed name of authorized person

Signature of authorized person

Official title

Authorized

person

E-mail address of authorized person

Telephone number

Date

(

)

Firm’s name

Firm’s EIN

Preparer’s PTIN or SSN

Paid

(or yours if self-employed)

preparer

Signature of individual preparing this report

Address

City

State

ZIP code

use

only

E-mail address of individual preparing this report

Preparer’s NYTPRIN

Date

(see instr.)

If not e-filing, attach this report to the parent corporation’s Form CT-3-A.

437002140094

Form Ct-3-A/c - Report By A Corporation Included In A Combined Franchise Tax Return - 2014 Page 2