Form Tc-69n - Utah State Tax Registration For Out-Of-State Beer Distributors Page 2

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1g. Officer/Owner Information
Enter the following information for each officer, general partner, managing member, trustee or enterprise owner. Attach additional sheets if you
need more space. Notify the Tax Commission if any changes occur.
Name and Title - PRINT
SSN and EIN
Home Address and City/State/ZIP
Phone Number
SSN
EIN
SSN
EIN
SSN
EIN
SSN
EIN
Section 2 – Activity Date
2a. When did you (or will you) start shipping beer into Utah?
Month
Day
Year
IMPORTANT: To protect your privacy, use the "Clear form" button when you are finished.
Clear form
If you need an accommodation under the Americans with Disabilities Act, contact the Tax Commission
at 801-297-3811 or TDD 801-297-2020. Please allow three working days for a response.
Page 2

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