Form Mc101 -Business Activity Questionnaire For Determining Minnesotacare Tax Nexus
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Business Activity Questionnaire for
Determining MinnesotaCare Tax Nexus
Legal name of business
Federal employer ID number (FEIN)
Date income year ends
Home office mailing address
Phone
Fax
City
State
Zip code
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:
Number of shareholders or partners
Percentage ownership of the partner/shareholder owning the largest share
%
Prior business names and dates of incorporation or organization, if any
Principal product or service
Brand names 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.
Enclose a copy of your most recent annual report.
Section A
Are you registered with the Secretary of State to do business in Minnesota? . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
If yes, enter the date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
/
/
2 Check the tax types for which you have filed a Minnesota return . Enter the years filed and FEIN if different from above .
Corporation franchise tax . . . . . . . . . . . From
to
. FEIN
S corporation tax . . . . . . . . . . . . . . . . . From
to
. FEIN
Partnership tax . . . . . . . . . . . . . . . . . . From
to
. FEIN
Sales/use tax . . . . . . . . . . . . . . . . . . . From
to
. FEIN
Withholding tax/unemployment tax . . . . From
to
. FEIN
Wholesale drug distributor tax . . . . . . . From
to
. FEIN
Health-care provider tax . . . . . . . . . . . . From
to
. FEIN
Hospital or surgical center tax . . . . . . . From
to
. FEIN
Prescription drug use tax . . . . . . . . . . . From
to
. FEIN
3 Are you licensed by the state of Minnesota to sell legend drugs at wholesale into Minnesota?
(If yes, continue with line 3a. If no, continue with line 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
a Check all that apply to indicate if you are a drug:
manufacturer
distributor
jobber
broker
b Have you sold your product(s) in the state of Minnesota? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
If yes, what types of products have you sold?
c Have you sold products by mail-order or Internet to Minnesota consumers? . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
If yes, what types of products have you sold?
4 Are you a pharmacy located in another state? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
5 Do you have a nonresident pharmacy license to sell legend drugs
at retail to consumers in Minnesota, including by mail order? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
6 Do you transport legend drugs either directly to a pharmacy in Minnesota that is a member of the same
corporation, or through a distributor to a pharmacy in Minnesota that is a member of the same corporation? . . . .
Yes
No
7 Does your company own or lease property in Minnesota? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
Continued
Minnesota Business Activity Questionnaire—MinnesotaCare Tax Nexus
(Rev . 8/06)
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Parent category: Financial