Form Ow-11 - Registration For Oklahoma Withholding For Nonresident Members Page 2

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Form OW-11 - Page 2

Revised 5-2012

Registration for Oklahoma Withholding for Nonresident Members

Names of Partners, Corporate Officers, and Managing Officer (continued)

Name (Last, First, Middle Initial)

Social Security Number or FEI N

Title

Mailing Address (street number, post office box, or rural route and box number)

City

State

Zip

County

Name (Last, First, Middle Initial)

Social Security Number or FEI N

Title

Mailing Address (street number, post office box, or rural route and box number)

City

State

Zip

County

Date you began or will begin withholding for nonresident members:

month/day/year

If you will use a different FEIN or SSN than shown in item 2

to report withholding tax, please list here:

Trade Name of Business (DBA):

Physical Location:

(street and number or directions, not post office box or rural route)

City

State

Zip

County

Person responsible for remitting withholding tax for nonresident members:

Name:

Title:

Phone Number:

Address to which reporting forms are to be mailed:

Mailing Address

City

State

Zip

A sole owner, general partner, corporate officer or authorized representative must sign this application.

I, the undersigned applicant or authorized representative, declare under the penalties of perjury that I have examined this application and attachments and, to the best of my

knowledge, the facts set forth are true and correct, and that the requirements hereunder will be carried out in accordance with the laws of the State of Oklahoma and the rules

and regulations of the Oklahoma Tax Commission. I further acknowledge and agree that withholding taxes are trust funds for the State of Oklahoma and that any use of these

trust funds other than timely remittance to the State of Oklahoma is embezzlement and can result in criminal prosecution.

Type or print name and title

Signature

Date

Mandatory inclusion of Social Security and/or Federal Employerʼs Identification Numbers are required on forms filed with the Oklahoma Tax Commission pursuant to Title 68

of the Oklahoma Statutes and regulations thereunder, for identification purposes, and are deemed part of the confidential files and records of the Oklahoma Tax Commission.

The Oklahoma Tax Commission is not required to give actual notice of changes in any state tax laws.