Form Mc101 - Minnesota Business Activity Questionnaire For Determining Minnesotacare Tax Nexus Page 2

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8 Does your company have employees, agents or independent contractors in Minnesota? . . . . . . . . . . . . . . . . . . .

Yes

9 Do you share information systems with an entity that has a physical presence in Minnesota? . . . . . . . . . . . . . . .

Yes

0 Do you have an agreement with an insurance company, HMO or self-insured employee health plan

in Minnesota that allows its beneficiaries to purchase goods or services through your company? . . . . . . . . . . . . .

Yes

Do you have a regional office serving Minnesota? If yes, enter the office location and the states it serves . . . . . .

Yes

Location

State(s)

2 Is your business listed in a Minnesota phone directory? If yes, enter city and phone number . . . . . . . . . . . . . . . .

Yes

City

Phone

3 Enter the date you began marketing or shipping your product into Minnesota . . . . . . . . . . . . . . . . . . . . . . . . . .

4 Do you ship or deliver products from another state into Minnesota?

(If yes, continue with line 14a. If no, continue with line 15) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

a List the states from which Minnesota destination sales are shipped or delivered:

b Do you have a distribution center located in Minnesota? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

c Describe your fulfillment process for Minnesota destination sales:

d To whom do you refer your customers for servicing? Provide name, address and phone number:

5 Have products been sent to Minnesota in returnable containers?

(If yes, continue with line 15a. If no, continue with line 16) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

a Do you retain ownership of the containers? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

b Do you charge a deposit on the containers? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

6 Check the activities performed using vehicles owned or leased by the business . Enter the years performed and frequency .

Deliver merchandise to Minnesota locations . . . . . Years

Frequency

Pick up own merchandise for return

to out-of-state locations . . . . . . . . . . . . . . . . . . . . Years

Frequency

Pick up products owned by another business . . . . . Years

Frequency

Pick up merchandise from one Minnesota location

for delivery to another Minnesota location . . . . . . . Years

Frequency

Have vehicle driver or passenger(s) make sales . . . Years

Frequency

7 Enter names, addresses and phone numbers of your three largest Minnesota customers:

8 Enter your Minnesota destination sales (sales, gross earnings or receipts) for each of the past three years:

9 Enter your total company sales (sales, gross earnings or receipts) for each of the past three years:

Section B

Has your business or subsidiary at any time had an office, agency, warehouse or other place

of business in Minnesota? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes

If yes, enter dates, location and nature of activities:

Continued

Minnesota Business Activity Questionnaire—MinnesotaCare Tax Nexus