Combined Registration Application For State Of Delaware Business License And/or Withholding Agent

COMBINED REGISTRATION APPLICATION

FOR

STATE OF DELAWARE

BUSINESS LICENSE AND/OR

DEPARTMENT OF FINANCE

DIVISION OF REVENUE

WITHHOLDING AGENT

820 N. French Street

DO NOT WRITE OR STAPLE IN THIS AREA

Wilmington, Delaware 19801

(302) 577-8778

THIS FORM MUST BE COMPLETED BY ALL PERSONS OR COMPANIES CONDUCTING BUSINESS ACTIVITIES IN DELAWARE

FOR OFFICE USE ONLY

FAILURE TO COMPLETE ALL QUESTIONS MAY RESULT IN DENIAL OF A BUSINESS LICENSE

TEMPORARY

PART A - TO BE COMPLETED BY ALL TAXPAYERS

Enter Employer Identification Number

or Social Security Number

Name

Mailing Address if Different

Trade Name (If different from above)

Primary Location Address

City

Country

State

Zip Code

City

Country

If business is Seasonal,

From: _____________ To: ___________

State Active Months

Month

State

Zip Code

Accounting Period (Check appropriate Box)

Enter Month and Day

DAY

of Fiscal Year Ending

Calendar Year

Fiscal Year - 12 Month Basis Ending

DAY

YEAR

DAY

YEAR

If Incorporated Enter

Date Incorporated

When did or when will you

State Incorporated

begin operating in Delaware

Type of Ownership (Check Appropriate box)

Fiduciary (Estate or Trust)

Insurance Company

LLC - Partnership

Sole Proprietorship

Cooperative

Limited Liability Company

LLC - Corporation

Partnership

Other: Explain ____________________________

Limited Liability Partnership

LLC - Non-Elect

Non-Profit Corporation

Holding/Investment Company

Delaware State Government

LLC - Non-Elect Individual

Corporation

QSSS

Professional Association

Delaware County Government

Sub-Chapter S Corporation

Employer - Domestic Employee(s)

Withholding Agent Only

Delaware Municipal Government

Federal Government

Bank

Other State's Government Agency

12 Sub Chapter S Corporations only - Do you have Shareholders that DO NOT reside in Delaware?

YES

Parent Company Name

Parent Employer

Identification Number

Previous Business Name

Previous Identification Number

EIN

SSN

(Circle One)

Name of individual who may be contacted regarding tax matters.

Phone

E-mail Address

FAX

Identify Owners, Partners, Corporate Officers, Registered Agent or Trustees:

Name: Last

First

Title

Social Security #

Fully Describe Business Activity (MUST BE COMPLETED)

PART B - TO BE COMPLETED BY ALL EMPLOYERS

Every employer making the payment of wages taxable to a resident or non-resident employee working in Delaware is required to withhold state income

taxes. Employers may also withhold Delaware state income tax from residents of Delaware who do not work in Delaware.

The filing frequency for a withholding agent is determined by the amount of withholding paid during a "lookback" period. The lookback period is a

twelve month period between July 1 and June 30 immediately preceding the calendar year for which the lookback period is determined. The Division of

Revenue will determine the amount of tax reported during the lookback period and advise all withholding agents of their withholding filing method. All

withholding agents having no prior record of withholding will file on a monthly basis until the next “lookback period”.

Amount of Withholding During “Lookback” Period

Filing Method

$3,600 or Less

Quarterly

$3,600.01 and Less Than $20,000

Monthly

$20,000.01 and Greater

Eighth Monthly

1. Will you have employees that work in Delaware, or withhold DE state income tax from DE residents that do not work in DE?

YES

2. Do you need a copy of the Delaware State Withholding Tax Tables?

YES

Sole proprietors and partners are responsible for filing and paying their own Delaware state taxes. This is done by remitting personal estimated taxes on a

quarterly basis. To obtain Personal Estimated Tax Packages; call the Individual Master File Unit at (302) 577-8588.

PLEASE NOTE: All employers are also required to register with the Delaware Department of Labor, Unemployment Insurance and report new

hires to the Division of Child Support Enforcement.

MAKE CHECK PAYABLE AND MAIL TO: DELAWARE DIVISION OF REVENUE, P.O. BOX 8750, Wilmington, DE 19899-8750

Rev. 9/2000

Combined Registration Application For State Of Delaware Business License And/or Withholding Agent - 2000

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