Form Cr-16 - Kansas Business Tax Application Page 4
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4ENTER YOUR EIN: ___ ___ __ ___ ___ ___ ___ ___ ___
OR
SSN: ___ ___ ___ __ ___ __ ___ ___ ___
PART 12
– OWNERSHIP DISCLOSURE AND SIGNATURE STATEMENT
List ALL owners, partners, corporate officers and directors. Provide the personal information and signatures of all persons who have
control or authority over how business funds or assets are spent. If more space is needed, attach additional pages.
Certification: To the best of my knowledge and belief the information on this application is true, correct, and complete. If the business fails
to report or pay appropriate state taxes, any individual who is responsible for the tax authorizes the Secretary of Revenue or his/her designee
to research the credit history of the business or that individual.
X
____________________________________________________
_____________________________________________________
Printed full proper name of owner, partner or corporate officer
Signature of owner, partner or corporate officer
Date
SSN: ________________________________________________
Title: ________________________________________________
Home address: ________________________________________
_____________________________________________________
(Street Address)
(City)
(State)
(Zip Code)
Home phone: __ __ __ __ __ __ __ __ __ __ E-mail: ____________________________________ Percent of Ownership: _______ %
ˆ
ˆ
Do you have control or authority over how business funds or assets are spent?
Yes
No
Date that you became the owner, partner or corporate officer of this business: Month ________ Day ________ Year ________
X
____________________________________________________
_____________________________________________________
Printed full proper name of owner, partner or corporate officer
Signature of owner, partner or corporate officer
Date
SSN: ________________________________________________
Title: ________________________________________________
Home address: ________________________________________
_____________________________________________________
(Street Address)
(City)
(State)
(Zip Code)
Home phone: __ __ __ __ __ __ __ __ __ __ E-mail: ____________________________________ Percent of Ownership: _______ %
ˆ
ˆ
Do you have control or authority over how business funds or assets are spent?
Yes
No
Date that you became the owner, partner or corporate officer of this business: Month ________ Day ________ Year ________
X
____________________________________________________
_____________________________________________________
Printed full proper name of owner, partner or corporate officer
Signature of owner, partner or corporate officer
Date
SSN: ________________________________________________
Title: ________________________________________________
Home address: ________________________________________
_____________________________________________________
(Street Address)
(City)
(State)
(Zip Code)
Home phone: __ __ __ __ __ __ __ __ __ __ E-mail: ____________________________________ Percent of Ownership: _______ %
ˆ
ˆ
Do you have control or authority over how business funds or assets are spent?
Yes
No
Date that you became the owner, partner or corporate officer of this business: Month ________ Day ________ Year ________
X
____________________________________________________
_____________________________________________________
Printed full proper name of owner, partner or corporate officer
Signature of owner, partner or corporate officer
Date
SSN: ________________________________________________
Title: ________________________________________________
Home address: ________________________________________
_____________________________________________________
(Street Address)
(City)
(State)
(Zip Code)
Home phone: __ __ __ __ __ __ __ __ __ __ E-mail: ____________________________________ Percent of Ownership: _______ %
ˆ
ˆ
Do you have control or authority over how business funds or assets are spent?
Yes
No
Date that you became the owner, partner or corporate officer of this business: Month ________ Day ________ Year ________
Send this form and any payments to: Kansas Department of Revenue, 915 SW Harrison St., Topeka, KS 66612-1588 or fax to: (785) 291-3614.
For assistance call (785) 368-8222.
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