Form 6401-Hmc - Application And Election For A Headquarters Management Corporation Business License Page 4

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PART F - COMPUTATION OF LICENSE FEE DUE WITH APPLICATION.
Each Headquarters Management Corporation must complete FORM 6401-HMC.
A Headquarters Management Corporation that is submitting an application after an affiliated Headquarters Management Corporation
has been approved is subject to the alternative License Fee calculated in Line 2.
1. Annual License Fee for first Headquarters Management Corporation.
Check here [ ] and remit $5,000.
If the election date on Part B, Line 1 is other than January 1
, apportion the License Fee based on the number of months
st
starting with the month of election through December, divided by twelve.
Multiple $5,000 x no. of months [
] / 12 = $
.
Check here [ ] and remit $
.
2. Annual License Fee for each additional Headquarters Management Corporation.
Check here [ ] and remit $500.
If the election date on Part B, Line 1 is other than January 1
, apportion the License Fee based on the number of months
st
starting with the month of election through December, divided by twelve.
Multiple $500 x no. of months [
] / 12 = $
.
Check here [ ] and remit $
.
I certify that I am authorized by the Applicant to make this election for Headquarters Management Corporation status and
that the foregoing information and attachments hereto are true, correct and complete to the best of my knowledge and belief:
Applicant’s Signature
Title
Date
Print Applicant’s Name
Approval of the Director of Revenue
[
] YES
[
] NO
Signature of the Director of Revenue
Date
(Revised 01/28/13)
*DF42813049999*

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