Form C102 - Minnesota Service Activity Questionnaire

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C102
Minnesota Service Activity Questionnaire
Legal Name of Business
Federal Employer ID Number (FEIN)
Date Income Year Ends
Home Office Mailing Address
City
State
Zip Code
Phone
Fax
Web Address
Email Address
Type of Business
State/Year of Incorporation or Organization
Year of Subchapter S Election
Corporation
S Corporation
Partnership __________Other
If S Corporation or Partnership, enter:
Percentage Ownership of the Partner/Shareholder Owning the Largest Share
Number of Shareholders or Partners __________________________
________________%
Prior Business Names and Dates of Incorporation or Organization, if any
Principal Product of Service
Brand Name of Products or Services
States or Countries from where Products/Services are Marketed or Shipped
Answer all questions with regard to the business listed above. Attach additional sheets if necessary to explain your answers.
1. Check the tax types for which your business has filed a Minnesota return. Enter the years filed and Federal ID
number (FEIN) if different from above.
Corporation Franchise Tax
From ____________________
to ___________________ FEIN _____________________
S Corporation Tax
From ____________________
to ___________________ FEIN _____________________
Partnership Tax
From ____________________
to ___________________ FEIN _____________________
Yes
No
2. Has your business ever received revenue from the sale of services to a Minnesota customer?
If yes, describe the services.
3. Has your business ever generated revenue from services performed outside of Minnesota for
a customer in Minnesota? If yes, explain the services performed.
4. Enter the date your business began marketing or soliciting sales of services from Minnesota customers. ______ / ______ / _____
5. Enter the names, addresses, and phone numbers of your three largest Minnesota customers.
Customer 1 ___________________________________________________________________________________________________
Customer 2 ___________________________________________________________________________________________________
Customer 3 ___________________________________________________________________________________________________
6. Enter your Minnesota “destination sales” for each of the past three years.
Destination sales are the total sales, gross earnings, or receipts from transactions with customers in Minnesota, without regard to
your company’s physical presence in Minnesota (See Minnesota Statutes, 290.015 & 290.191 subdivisions 5 and 6).
Year ___________ $ _____________
Year __________
$ ____________
Year ____________
$ _____________
7. Enter your total company sales (sales, gross earnings or receipts) for each of the past three years.
Year ___________ $ _____________
Year __________
$ ____________
Year ____________
$ _____________
8. Enter your net income/ordinary income (before net operating loss deduction) for each of the past three years.
Year ___________ $ _____________
Year __________
$ ____________
Year ____________
$ _____________
Continued
(Rev. 6/16)

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