REG-1, Illinois Business Registration Application€¦ · REG-1 (R-09/18) Illinois Department of...

REG-1 (R-09/18)

Illinois Department of Revenue

REG-1 Illinois Business Registration Application

Register faster using MyTax Illinois, our online account management program, available at mytax.illinois.gov. If you have questions, visit our website at tax.illinois.gov or call us weekdays between 8:00 a.m. and 4:30 p.m. at 217 785-3707.

Step 1: Identify your business or organization 1 Federal employer identification number (FEIN)

FEIN: ______ - __________________

Proprietorships must provide the Social Security number (SSN) under which taxes will be filed.

SSN: _________ - ______ - ____________

2 Legal business name:

___________________________________________________ 3 Doing-business-as (DBA), assumed, or trade name, if different from Line 2:

___________________________________________________ 4 Primary or legal business address:

___________________________________________________ Street address - No PO Box number Apartment or suite number ___________________________________________________ City State ZIP

If you have other locations in Illinois from where you do business, complete and attach Schedule REG-1-L.

5 Mailing address if different from the address above:

___________________________________________________ In-care-of name

___________________________________________________ Street address or PO Box number Apartment or suite number

___________________________________________________ City State ZIP

6 Check the organization type that applies to you:

Proprietorship ____ Check if owned by a married couple or civil union

Partnership Trust or estate

Corporation* S Corp (Subchapter S Corporation)* * Is your corporation publicly traded? ___ Yes ___ No If yes, provide the ticker symbol ____________

Governmental unit Not-for-profit organization

LLC - Corporation LLC - Partnership

LLC - Single member ____ Check if disregarded If you are applying to be a Scholarship Granting Organization under the Invest in Kids Act of 2017, you must apply online using MyTax Illinois, available at mytax.illinois.gov.

7 Illinois Secretary of State identification number:

___ - ___ ___ ___ ___ - ___ ___ ___ - ___

8 Is your business part of a unitary group? ___ Yes ___ No If “Yes”, provide the FEIN of your designated agent (the entity responsible for filing your Illinois income tax return):

FEIN: ______ - __________________

9 Identify a contact person regarding your business.

Name: __________________________ Title: _____________

Phone: (______) ______ - ________ Ext.: __________

FAX: (______) ______ - ________

Email address: ______________________________________

Step 2: Identify your owners and officers - If you need to identify more, attach Schedule REG-1-O.

10 Identification depends on the organization type you selected in Step 1, Line 6 (proprietorship - owner(s); partnership - general partners; non-publicly traded corporation - president, secretary, and treasurer; publicly traded corporation - chief operating officer and chief financial officer; trust or estate - trustee(s) or executor(s); governmental unit - one contact person; not-for-profit organization - president, secretary, or treasurer; limited liability company - managers and members). For each individual or business required, complete the following information.Individuals: (include Social Security number (SSN))

a ___________________________________ _________________ Name Title

______________________________________________________ Home address - No PO Box number City State ZIP

____ / ____ / ________ (______) ______ - ________ Date of birth Phone

_______ - _____ - _________ Ownership percentage: ______ Social Security number

b ___________________________________ _________________ Name Title




c ___________________________________ _________________ Name Title




d ___________________________________ _________________ Name Title




Businesses: (include federal employer identification number (FEIN))

a ___________________________________ ____-_____________ Name FEIN

______________________________________________________ Legal address

______________________________________________________ City State ZIP

(______) ______ - ________ Ownership percentage: ______ Phone

b ___________________________________ ____-_____________ Name FEIN

______________________________________________________ Legal address

______________________________________________________ City State ZIP

(______) ______ - ________ Ownership percentage: ______ Phone

*874501110*

DianeYetter

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REG-1 (R-09/18)

This form is authorized as outlined under the tax or fee Act imposing the tax or fee for which this form is filed. Disclosure of this information is required. Failure to provide information may result in this form not being processed and may result in a penalty.

Printed by the authority of the State of Illinois - Web only - One copy

Mail your completed form, with any required attachments and payment to:

CENTRAL REGISTRATION DIVISION ILLINOIS DEPARTMENT OF REVENUE PO BOX 19030 SPRINGFIELD IL 62794-9030

Step 4: Sign below Under penalties of perjury, I state that I have examined this information and, to the best of my knowledge, it is true, correct, and complete. I further attest that I will be responsible for filing returns and paying all taxes due unless Schedule REG-1-R, Responsible Party Information, is attached to this application or forwarded to the department. Check here if you are attaching or forwarding Schedule REG-1-R:

Signature: _______________________________________ Title: ________________________ Date: ___/___/______

Printed name: _______________________________________ SSN: ______ - _____ - _________

Address: _______________________________________ Phone: (______) ______ - _________

*874512110*

Step 3: Tell us about your business activities 11 Describe your business activities: ______________________ ____________________________________________ Provide your North American Industry Classification System (NAICS) number: ___________________________________ Refer to the website www.naics.com

12 Will you have Illinois employees? ____ Yes ____ No If yes, complete and attach Schedule REG-UI-1. When was (is) the date of your first payroll in Illinois? ____/____/_____ 13 Check all that apply to your type of business.

Sales You must complete and attach Schedule REG-1-L to identify

all Illinois locations from which you make retail sales. General merchandise: ____ Retail ____ Wholesale Note: You must check “Retail” above if you make retail

sales that are filled from inventory that is maintained in Illinois prior to its delivery to your Illinois purchaser.

Sales to Illinois customers from out of state ____ Check here if you have an Illinois presence,

including, but not limited to having an office or other facility in Illinois or having employees or other representatives operating in Illinois.

____ Check here if you make $100,000 or more in annual sales to Illinois customers.

____ Check here if you make 200 or more separate transactions annually to Illinois customers.

Do you estimate your monthly sales and use tax liability will be over $200? ____ Yes ____ No

Soft drinks (other than fountain soft drinks) in Chicago Vehicle, watercraft, aircraft, or trailers Sales or delivery of tires. Do you always pay the Tire User Fee to your supplier? ____ Yes ____ No Sales from vending machines. How many vending

machines? ____ Liquor at retail (bar, tavern, liquor store, etc.) Motor fuel/fuel: ____ Retail ____ Wholesale ____ Check here if you are required to collect prepaid

sales tax. Medical cannabis - Attach Schedule REG-1-MC. ____ Cultivation Center ____ Dispensing Organization Aviation fuel: ____ Retail ____ Wholesale (if wholesale, attach Schedule REG-8-A) When will (did) these activities begin? ____/____/_____

Services Do you transfer items, on which tax must be collected, as part of

your service? ____ Yes ____ No When will (did) this activity begin? ____/____/_____

Use Does your supplier collect Illinois Sales Tax for merchandise your

business uses or consumes in Illinois? ____ Yes ____ No Does your supplier collect Illinois Sales Tax on sales of aviation

fuel your business uses or consumes in Illinois? ____ Yes ____ No When will (did) these activities begin? ____/____/_____

Cigarettes and other tobacco products Cigarettes - See Schedule REG-1-C before you check here. Tobacco products - See Schedule REG-1-C before you check

here. Cigarette machine operator - See Schedule REG-1-C before

you check here. When will (did) these activities begin? ____/____/_____

Renting or leasing Hotel rooms for less than 30 days - Attach Schedule REG-1-L. Do you charge for telecommunication services? ____ Yes ____ No Vehicles for one year or less - Attach Schedule REG-1-L. Vehicles for more than one year When will (did) these activities begin? ____/____/_____

Utility providers Electricity: ____ Retail ____ Wholesale Natural gas: ____ Retail ____ Wholesale Telecommunications - See Schedule REG-1-T. ____ Retail ____ Wholesale Water or sewer services Are you a utility cooperative? ____ Yes ____ No Are you a municipality? ____ Yes ____ No When will (did) these activities begin? ____/____/_____

All other tax types Liquor warehousing - Attach Schedule REG-1-A. Dry cleaning: ____ Facility ____ Solvent supplier Own/operate coin-operated amusement devices You wish to purchase electricity for non-residential use and pay

the tax to IDOR - Attach Schedule REG-1-D. You wish to purchase natural gas from outside of Illinois for your own use and pay the tax to IDOR - Attach Schedule REG-1-G. Not listed. Identify: ___________________________________ When will (did) these activities begin? ____/____/_____

DianeYetter

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DianeYetter

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DianeYetter

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DianeYetter

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DianeYetter

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Permanent Location 3:

DBA name:____________________________________________

Address: _____________________________________________ Street address - No PO Box numbers Apt. or suite no.

_____________________________________________ City State ZIP

County:_______________________________________________

If in Madison or St. Clair county, list township: _________________

Contact: ____________________ Phone: (____)____ - _______

Starting date for this location: ____/____/_______

Check all of your activities at this location:

Retail sales Aviation Fuel Vehicles: Sales Renting/leasing Check if your rental/lease agreements are for more than12 months: Hotel room rental to the public for periods less than 30 days. Do you charge for telecommunication services? ___yes ___no Other: ______________________________________________


DBA name:____________________________________________


_____________________________________________ City State ZIP

County:_______________________________________________


Contact: ____________________ Phone: (____)____ - _______




Illinois Department of Revenue Schedule REG-1-L Illinois Business Site Location Information Attach to Form REG-1

Business name: _________________________________________ FEIN: ______ - __________________

Contact for this schedule:_________________________________ SSN: _________ - ______ - ____________ (Proprietorship only)

Phone: (_____) ______ - ___________


DBA name:____________________________________________


_____________________________________________ City State ZIP

County:_______________________________________________


Contact: ____________________ Phone: (____)____ - _______





DBA name:____________________________________________


_____________________________________________ City State ZIP

County:_______________________________________________


Contact: ____________________ Phone: (____)____ - _______




174530101

IL

IL IL

IL

REG-1-L front (R-11/17)

Step 1: Identify each permanent location.

Read this information first.Complete Schedule REG-1-L, to identify all Illinois locations from which you will make retail sales, rent/lease vehicles, and/or rent or lease hotel rooms to the public for periods of less than 30 days. You must also identify the same location you did on Form REG-1, Line 4, if the activities at that location include retail sales or rental/leases. In Illinois some tax rates vary based upon the specific location of the business activities. The location of your business will determine the tax rate that we will preprint on your return. We recognize three types of locations: Permanent - Examples include a building, warehouse, or storefront. To identify these, complete Step 1. Changing - A changing location is one that constantly changes (e.g., door-to-door sales, home party sales). If you have changing locations, complete Step 2. You must identify sales from a vending machine as a changing location. Temporary - Examples include a fair, festival, or convention. To identify temporary locations, complete Step 3. Special events or seasonal sales should also complete Step 3.

To identify more locations, attach a sheet using a similar format. If you have previously registered and need to add a location, call us at 217 785-3707.

This form is authorized as outlined under the tax or fee Act imposing the tax or fee for which this form is filed. Disclosure of this information is required. Failure to provide information may result in this form not being processed and may result in a penalty.

Printed by the Authority of the State of Illinois (web only)

Changing Location 4:

DBA name:____________________________________________

Municipality:___________________________________________

County:_______________________________________________

If in Madison or St. Clair county, list township: ___________________

Starting date: ____/____/_______


DBA name:____________________________________________

Municipality:___________________________________________

County:_______________________________________________


Starting date: ____/____/_______


DBA name:____________________________________________

Municipality:___________________________________________

County:_______________________________________________


Starting date: ____/____/_______


DBA name:____________________________________________

Municipality:___________________________________________

County:_______________________________________________


Starting date: ____/____/_______


DBA name:____________________________________________

Municipality:___________________________________________

County:_______________________________________________


Starting date: ____/____/_______


DBA name:____________________________________________

Municipality:___________________________________________

County:_______________________________________________


Starting date: ____/____/_______

Step 2: Identify each changing location A changing location is one that constantly changes (e.g., door-to-door sales, home party sales).

174530102

Step 3: Identify each temporary location Examples include fairs, festivals, or special events. Seasonal sales (e.g., trade-shows, holiday sales, concession stands) are considered a temporary location.

IL IL

Temporary Location 2:

DBA name:____________________________________________


_____________________________________________ City State ZIP

County:_______________________________________________

If in Madison or St. Clair county, list township: __________________

Contact: ____________________ Phone: (____)____ - _______


Sales Vehicle sales Other: ___________________________________________

Check if your business activities are seasonal or for a special event. Provide the following dates.

Starting: ____/____/_______ Ending: ____/____/_______

Temporary Location 1:

DBA name:____________________________________________


_____________________________________________ City State ZIP

County:_______________________________________________


Contact: ____________________ Phone: (____)____ - _______


Sales Vehicle sales Other: ___________________________________________

Check if your business activities are seasonal or for a special event. Provide the following dates.

Starting: ____/____/_______ Ending: ____/____/_______

REG-1-L back (R-11/17)

Step 2: Entity Information11 What is your primary business activity in Illinois?

___________________________________________________________

What is your principal product or service?

___________________________________________________________

If you have more than one product or service, list the top two and indicate the percentages that each contributes to your total revenue:

_____________________________ % of Sales or receipts _______

_____________________________ % of Sales or receipts _______

Enter your NAICS Code here ____________________________(If you do not know your NAICS Code refer to the Bureau of Labor Statistics website for the proper code)

12 If you are a Corporation:

Date of Incorporation __________ State in which incorporated______

Has any form of remuneration, including dividends, been paid to the officers of this corporation? q Yes q No

13 If you are a Limited Liability Company (LLC):Are there any individuals performing services for the organization other than the member manager(s)? q Yes q No

How is the member manager(s) treated for federal tax purposes?

q Sole Proprietor q Partner q Other (Explain) ____________________

If you are an LLC-Corporation indicate:

Date of Organization __________ State in which Organized

14 If you are a Partnership:Are there any individuals performing services other than the partners?q Yes q No

15 If you are a Sole Proprietor:Are there any individuals performing services, other than the sole proprietor, the sole proprietor’s parent, spouse or child under the age of 18?q Yes q No

18 Did you acquire your Illinois business or any portion of it by purchase, reorganization or a change in entity; for example, a change from sole proprietor to corporation? q Yes q No If yes, you must complete and attach form UI-1 S&P, Report to Determine Succession. Also complete the remainder of the questions on this form. Responses to the questions on this form should reflect information relative to the operation of your business after the date of acquisition.

Step 3: Liability Information19 Have you incurred liability under the Federal Unemployment Tax Act (in

any state) for any of the last 4 years? q Yes q No

If yes, indicate the year(s) for which you incurred such liability:

_______________________________________________________

Step 4: Additional Liability InformationIf you are not engaged in Domestic, Agricultural, Religious, Charitable, Educational, Nonprofit or Governmental services, skip to question 24.

20 Domestic Service EntitiesIn regard to domestic service workers, in a private home, local college club, or local chapter of a college fraternity or sorority, if applicable check any of the following:a q If during the current calendar year, the past four calendar

years, or the future four calendar quarters, there have been or there will be any quarter in which you paid wages of $1,000 or more for domestic service.

Check the first such quarter during that period and indicate the year in which it did or will occur:

q Jan-Mar (Q1) ________ q Apr-Jun (Q2) ________

q Jul-Sept (Q3) ________ q Oct-Dec (Q4) ________

b q If you solely employ household workers and are eligible to use Schedule H (IRS Form 1040) for filing federal unemployment taxes for the workers (whether or not you use it), then you may elect to pay contributions for each quarter and submit wage reports for each month or quarter, as the case may be, on an annual basis. Check this box (20b) if you are eligible and would like to elect to file annually.

Illinois Department of Employment Security and the Illinois Department of Revenue

REG-UI-1 Report to Determine Liability Under the Unemployment Insurance Act

Read this information first Register faster using MyTax Illinois, our online account management program, at mytax.illinois.gov. If you have questions contact us weekdays between 8:30 a.m. and 5:00 p.m. at (800) 247-4984.

Important: Every newly created employing unit shall file this report within 30 days of the date upon which it commences business (820 ILCS 405/1800; 56 Ill. Adm. Code 2760.105). If you are registering a new business, complete and attach this form to your REG-1, Illinois Business Registration Application, available on the Illinois Department of Revenue website at tax.illinois.gov.

Step 1: Business Information 1 Business Name: _______________________________________ 2 Doing Business As: ______________________________________

3 Primary Business Address: _______________________________________________________________________________________

4 Secondary Address: _____________________________________________________________________________________________

5 Phone Number: ______________________________________ 6 E-mail Address: __________________________________________

7 FEIN: _____-________________________ 8 IDES previously assigned employer account no.:____________________________

9 Type of organization (check one): qAssociation qCooperative qC-Corporation qGovernment qMunicipal Government qPolitical Subdivision qInstrumentality qLLC-Corporation qLLC-Partnership qLLC-Single Member qPartnership qReceiver qS-Corporation qSole Proprietor qTrustee in Bankruptcy qTrust/Estate qOther: _____________________________________

10 Is this a qualified settlement fund? qYes qNo

16 Date you first began employing workers in Illinois: ______________

17 Date of your first payroll in Illinois: ______________

REG-UI-1 front (R-09/17)

(If address is a non-Illinois headquarters you are required to also answer question 4)

(If applicable)

(Physical location of your Illinois business or a secondary address where you conduct business in Illinois. If there is no additional address leave blank. If you want IDES correspondence sent to any other address than question 3 and 4, complete and attach IDES Form UI-1M Special Mailing Form and LE-10, Power of Attorney, if applicable)

(Describe)

21 Agricultural EntitiesIn regard to agricultural labor, if applicable check any of the following:

a qYou employ, have employed, or will employ one of more workers to perform agricultural labor.

b qDuring the current calendar year, the past four calendar years, or the future four calendar quarters, there has been or there will be any quarter in which you paid wages of $20,000 or more for agricultural labor.

If so, check the first such quarter during that period and indicate the year in which it did or will occur:q Jan-Mar (Q1) ________ q Apr-Jun (Q2) ________


c qDuring the current calendar year, the past four calendar years, or the future four calendar quarters, there has been or there will be any calendar year during which you employed 10 or more individuals to perform agricultural labor for at least 20 weeks (whether consecutive or not).



d qIf you checked 21a, 21b or 21c and your business includes any retail sales activity, check this box (21d).

22 Religious, Charitable, Educational or Other Nonprofit Entitiesa qCheck if your organization is a religious, charitable, educational

or other nonprofit organization as defined in Section 501(c)(3) of the Internal Revenue Code. If so, attach your federal IRS 501(c)(3) exemption letter to this application.

b qDuring the current calendar year, the past four calendar years, or the future four calendar quarters, there have been or there will be any quarter in which you have had four or more workers to perform work for at least 20 weeks (whether or not consecutive).

If so, check the quarter that included the 20th week within which you have employed 4 or more individuals to perform religious, charitable education and/or nonprofit labor and indicate the year in which it did or will occur:

q Apr-Jun (Q2) ________ q Jul-Sept (Q3) ________

q Oct-Dec (Q4) ________

c q Check if you wish to be a reimbursable employer. Complete and attach form UI-5NP, Reimburse Benefits in Lieu of Paying

Contributions.

23 Governmental Entities or Indian Tribes

a q Check if you wish to be a reimbursable employer. Complete and attach form UI-5LG, Reimburse Benefits in Lieu of Paying

Contributions. b q Check if your organization is an Indian Tribe (including a

subdivision, subsidiary or business enterprise wholly owned by an Indian Tribe).

24 If you did not answer 20, 21, 22, 23, check any of the following boxes that apply and provide the requested information.

a q Have there or will there be, any calendar quarter in either the current calendar year, the past four calendar years, or the future four calendar quarters, in which you paid wages of at least $1,500 for services in employment.



b q Have there or will there be, any calendar quarter in either the current calendar year, the past four calendar years, or the future four calendar quarters, in which you have had one or more individuals performing services in employment in each of at least 20 weeks (whether consecutive or not).

If so, check the first such quarter during that period and indicate the year in which it did or will occur:q Apr-Jun (Q2)

q Oct-Dec (Q4)

q Jul-Sept (Q3)

Step 5: Additional Business Information25 Voluntary Coverage

If you are determined to be not liable for the payment of unemployment insurance taxes based upon the provisions of the Illinois Unemployment Insurance Act you may voluntarily elect coverage under 820 ILCS 405/302.

q Check if you want voluntary coverage, complete and attach FormUI-1B, Voluntary Election of Coverage.

26 If you have multiple worksites in Illinois complete and attach Form UI-ML, Multiple Worksites in Illinois, found online at ides.illinois.gov.

This state agency is requesting information that is necessary to accomplish the statutory purpose as outlined under 820 ILCS 405/100-3200. Disclosure of this information is required. Failure to disclose this information may result in statutorily prescribed liability and sanction, including penalties and interest.

Step 6: Certification and SignatureI hereby certify that the information contained in this report, and any sheets or forms attached hereto, is true and correct. This report must be signed by the owner, a partner, or an authorized agent within the employing enterprise. If this document is signed by any other person, complete and attach the Illinois Department of Employment Security Form LE-10, Power of Attorney, available online at ides.illinois.gov.

Printed Name: _____________________________________ Signature: _____________________________________________

Title: ____________________________________________ Date: ____________________

REG-UI-1 back (R-09/17)

Mail your completed form, with any required attachments to:

CENTRAL REGISTRATION DIVISION ILLINOIS DEPARTMENT OF REVENUE PO BOX 19030 MAIL CODE 3-222 SPRINGFIELD IL 62794-9030

Printed by the authority of the State of Illinois (web only)

REG-UI-1

Illinois Department of Employment Security and the Illinois Department of Revenue ________________________________________________________________________________________________________________________

INSTRUCTIONS FOR PREPARATION OF THE REG-UI-1 REPORT TO DETERMINE LIABILITY UNDER THE UNEMPLOYMENT INSURANCE ACT

________________________________________________________________________________________________________________________

An employing unit must file the Report to Determine Liability (IDES Form REG-UI-1) even though it may not be liable for payments under the Illinois Unemployment Insurance Act (the Act).

Read the instructions below carefully. The Guide to the Illinois Unemployment Insurance Act is available on our website at: www.ides.illinois.gov. It will assist you in filling out the form.

Type or print in ink your answer to each item that applies. If you need more space, attach additional sheets but mark each "Supplement to REG-UI-1" and sign and date it. If you are registering a new business, complete and attach this form to your REG-1, ILLINOIS BUSINESS REGISTRATION APPLICATION, available on the Illinois Department of Revenue website at tax.illinois.gov.

1. Business Name: Legal name of the employer. If the entity is a Sole Proprietor, the owner's name; if a Partnership, the partners' names and type of partnership (such as a general partnership, limited partnership or joint venture); if a Corporation, the corporate name with the word "Corporation,""Incorporated," "Company," "Limited," or their abbreviations; if a Limited Liability Company, the name must contain the phrase Limited LiabilityCompany, or its abbreviation.

2. Doing Business As: Enter the trade name of your business. If there is no trade name being used, leave this item blank.

3. Primary Address: Enter the address of the physical location of your Illinois business. If there is no base of operations in Illinois, enter the non-Illinois headquarters address.

4. Secondary Address: Enter any secondary address where you conduct business in Illinois. If there is no additional address, leave this item blank.If you want IDES correspondence sent to any other address than your answers to Questions 3 and 4, complete and attach IDES form UI-1M (Unemployment Special Mailing Form) and, if applicable, IDES Form LE-10 (Power of Attorney).

5. Phone Number: Telephone number to the business, business owner or person responsible for Unemployment Insurance taxes.

6. E-mail Address: E-mail to the business, business owner or person responsible for Unemployment Insurance taxes.

7. FEIN(Federal Employer Identification Number) assigned by the Internal Revenue Service for reporting Social Security, Withholding and FederalUnemployment Tax.

8. IDES previously assigned employer account no.: If known, this will be a seven digit number issued by IDES.

9. Type of organization: Check one of the organization types listed - please note there are two types of Corporations and three different types ofLLCs to choose from, pick accordingly.

10. A Qualified Settlement Fund is a fund, account or trust that has been established to resolve or satisfy one or more claims resulting from at leastone claim asserting liability (for example, a class action settlement involving wage and hour issues).

11. Enter the business activity that produces your major source of income. List products manufactured, commodities sold, activities engaged in or type of services rendered. For more than one business activity within the employing unit, indicate the percentage that each contributes to revenue. Enter the six digit NAICS code that best describes your primary business activity. (If you do not know your NAICS Code refer to the Bureau ofLabor Statistics website for the proper code. The website address is: https://www.bls.gov/bls/naics.htm.

12.If your business is a Corporation, answer all components within this question.

13.If you are a Limited Liability Company, answer all components within this question.

14.If you are a Partnership, answer all components within this question.

15.If you are a Sole Proprietor, answer all components within this question.

16.Enter the full date (MM/DD/YYYY) on which you first began employing workers, not the date when wages were first paid out.

17.Enter the full date (MM/DD/YYYY) on which you first paid wages in the State of Illinois.

18.If "yes", refer to the directions given beneath question 18 and submit only the IDES form, UI-1S&P Report to Determine Succession to IDES; 33 SState St 10th floor; Chicago, IL 60603.

19.If you have been found liable for Federal Unemployment taxes, you immediately become liable to Illinois for state unemployment insurance taxesbeginning with your first Illinois payroll.

20."Domestic service" means service of a household nature, including services performed by cooks, waiters, butlers, housekeepers, housemothers,

governesses, maids, valets, babysitters, janitors, launderers, furnace men, caretakers, handymen, gardeners, footmen, grooms and chauffeurs of automobiles for family use. Service not of a household nature, such as by a private secretary, nurse, tutor or librarian, is not considered "domestic" service.

A "private home" is the fixed place of abode of the individual or family for whom the worker is performing services. A separate and distinct dwelling unit maintained by an individual as a residence, such as a hotel room, boat or trailer, can be a "private home." A room or suite in a nursing home can be a "private home," provided that the facts and circumstances of the particular case indicate that such room or suite is, in fact, the place where the individual retains his residence. A home utilized primarily for the purpose of supplying board or lodging to the public as a business enterprise is not a "private home."

A "local college club" or "local chapter of a college fraternity or sorority" does not include an alumni club or chapter.

21."Agricultural labor" means all services performed:

• On a farm, in the employ of any person, in connection with cultivating the soil or in connection with raising or harvesting any agricultural orhorticultural commodity, including the raising, shearing, feeding, caring for, training, and management of livestock, bees, poultry and fur-bearing animals and wildlife;

• In the employ of the owner or tenant or other operator of a farm, in connection with the operation, management, conservation, improvement or maintenance of such farm and its tools and equipment;

• In connection with the ginning of cotton, or the operation or maintenance of ditches, canals, reservoirs or waterways not owned or operated for profit, used exclusively for supplying and storing water for farming purposes;

• In the employ of the operator of a farm, or of a group of operators of farms (or a cooperative organization of which such operators are members), in handling, planting, drying, packing, packaging, processing, freezing, grading, storing or delivering to storage or to market or to acarrier for transportation to market, in its unmanufactured state, any agricultural or horticultural commodity; but only if such operator or operators produced more than one-half of the commodity with respect to which such service is performed. The provisions of this subsection shall not be deemed to be applicable with respect to service performed in connection with commercial canning or commercial freezing or in connection with any agricultural or horticultural commodity after its delivery to a terminal market for distribution for consumption.

• For purposes of questions 21b & 21c, count each week in which you had or expect to have 10 or more individuals to perform agricultural labor, whether or not they all worked or will work at the same time during that week and whether or not you employed or will employ the same individuals in each week.

"Week" means the seven day period, Sunday through Saturday.

22. For purposes of question 22b, count each week in which you expect to have 10 or more individuals performing services in employment, whetheror not they all worked or will work at the same time during that week and whether or not you employed or will employ the same individuals in each week.

"Week" means the seven day period, Sunday through Saturday. "Employment" means any service performed by an individual for an employing unit, unless the Unemployment Insurance Act expressly excludes the service from the definition of "employment." It includes service in interstate commerce and service on land which is owned, held or possessed by the United States, and includes all services performed by an officer of a business corporation, without regard to whether such services are executive, managerial or manual in nature, and without regard to whether such officer is or is not a stockholder or a member of the board of directors of the corporation.

Benefit Reimbursable Option: Each nonprofit organization subject to the Act may, if certain conditions are met, elect to be a reimbursable employer by agreeing, in lieu of paying contributions, to reimburse the State for the actual amount of regular benefits and one half the amount of extended benefits that are charged to it.

23. "Employment" means any service performed by an individual for an employing unit, including a governmental entity or Indian tribe, unless the Unemployment Insurance Act expressly excludes the service from the definition of "employment.""Governmental entity" includes the State or any of its instrumentalities, or any political subdivision or municipal corporation thereof or any of their instrumentalities, or any instrumentality of more than one of the foregoing, or any instrumentality of any of the foregoing and one or more other Statesor political subdivisions. "Indian Tribe" means any Indian tribe, band, nation or other organized group or community, including any Alaskan Native village or regional village orcorporation, which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status asIndians, and includes any subdivision, subsidiary or business enterprise wholly owned by an Indian tribe. Benefit Reimbursable Option: Each governmental entity or Indian Tribe subject to the Act may, if certain conditions are met, elect to be areimbursable employer by agreeing, in lieu of paying contributions, to reimburse the State for the actual amount of regular benefits and one half the amount of extended benefits that are charged to it.

24. "Employment" means any service performed by an individual for an employing unit, unless the Unemployment Insurance Act expressly excludesthe service from the definition of "employment." It includes service in interstate commerce and service on land which is owned, held or possessed bythe United States, and includes all services performed by an officer of a business corporation, without regard to whether such services are executive, managerial or manual in nature, and without regard to whether such officer is or is not a stockholder or a member of the board of directors of the corporation. For purposes of question 24b, count each week in which you had or expect to have 1 or more individuals performing services in employment, whetheror not they all worked or will work at the same time during that week and whether or not you employed or will employ the same individuals in each week. "Week" means the seven day period, Sunday through Saturday.

25.If an employing unit does not meet the legal definition of an employer for unemployment insurance purposes, the employing unit can elect to be fully

liable subject to the Illinois Unemployment Insurance Act with the permission of the Director. An employing unit electing such coverage will not be able to terminate its coverage until January 1 of any calendar year subsequent to two such years of coverage.

26.If you have multiple worksites in Illinois, refer to the directions given in question 26 and submit the IDES form, UI-ML, Multiple Worksites in Illinois,found online at ides.illinois.gov, with this completed form If you should need further assistance in filling out this form, you may contact the Illinois Department of Employment Security (IDES) weekdays between 8:30 a.m. and 5:00 p.m. at (800) 247-4984. Please make a copy of this completed REG-UI-1 form and any additional formssubmitted for your records.

10A100(P)(06-18)Commonwealth of KentuckyDEPARTMENT OF REVENUE

FOR OFFICE USE ONLY

CBI #

FEIN

CRIS #

RCS Flag NAICS

Coded/Date Coded Data Entry/Data Entered

WH SU TEL CU CT CP NRWH

TR UTL CID LL

TF

CMRS

SECTION A REASON FOR COMPLETING THIS APPLICATION (Must Be Completed)

SECTION B BUSINESS / RESPONSIBLE PARTY / CONTACT INFORMATION (Must Be Completed)

4. Legal Business Name 5. Doing Business As (DBA) Name (See instructions) 6. Federal Employer Identification Number (FEIN) (Required, complete prior to submitting) 7. Kentucky Commonwealth Business Identifier (if already assigned) 8. Secretary of State Information (if applicable)

Kentucky Secretary of State Organization Number

/ /

Date of Incorporation/Organization State of Incorporation/Organization

/ /

If you are an Out-of-State Entity, Date of Qualification with the Kentucky Secretary of State’s Office

—

1. Effective Date 3. Previous Account Numbers (If applicable)

Opened new business/Began activity in Kentucky Resumption of business Hired employees working outside KY who have a KY residence

Applying for other accounts/Began a new taxable activity

Bidding for state government contract (State Vendor or Affiliates)

Purchased an existing business (See instructions) Purchased business assets from previous owner Yes No

Business structure change or conversion (Specify previous type; See instructions) Change of Federal Identification Number (FEIN), Kentucky Secretary of State Organization Number, or Commonwealth Business Identifier (CBI) Other (Specify)

/ /Kentucky Employer’s Withholding Tax __________________

Kentucky Sales and Use Tax __________________

Kentucky Telecommunications Tax __________________

Kentucky Utilities Gross Receipts License Tax __________________

Kentucky Consumer’s Use Tax __________________

Kentucky Corporation Income Tax and/orLimited Liability Entity Tax __________________

Kentucky Coal Severance & Processing Tax __________________

Kentucky Pass-Through Non-Resident Withholding __________________

Federal ID Number (FEIN) __________________

Kentucky Secretary of State Organization Number __________________

Commonwealth Business Identifier (CBI) __________________

• Incomplete or illegible applications will delay processing and will be returned.• See instructions for questions regarding completion of the application.• Need Help? Call (502) 564-3306 or Email [email protected]

KENTUCKY TAX REGISTRATION APPLICATION

For faster service, apply online athttp://onestop.ky.gov

To update information for your existing account(s) or report opening a new location of your current business, use Form 10A104, Update or Cancellation of Kentucky Tax Account(s).

2. A. Did you receive correspondence from the Division of Registration and Data Integrity requesting registration of this business?

Yes No

B. If Yes, enter the File Number located at the top of the letter you received.

File Number

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13. Business Structure

14. How Will You be Taxed for Federal Purposes? (Sole Proprietorships, HCSRs, Qualified Joint Ventures, Estates, Governments, and Unincorporated Non-Profits SKIP question 14)

15–16. OWNERSHIP DISCLOSURE–RESPONSIBLE PARTIES (REQUIRED FOR ALL BUSINESS STRUCTURES)

Profit Limited Liability Company (LLC)

Non-Profit Limited Liability Company (LLC)

Professional Limited Liability Company (PLLC)

Series of a Limited Liability Company

Profit Corporation

Non-Profit Corporation

Professional Service Corporation (PSC)

Cooperative Corporation

Limited Cooperative Association

Association

Statutory Trust

Series of a Statutory Trust

Business Trust

Trust (Non-statutory)

Limited Partnership (LP)

Limited Liability Partnership (LLP)

Limited Liability Limited Partnership (LLLP)

Series of a Partnership

General Partnership

Joint Venture

Estate

Government

Unincorporated Non-profit Association

Sole Proprietorship

Home Care Service Recipient (HCSR)

Qualified Joint Venture (Married Couple)

Protected Cell Company (PCC)

Cell of a Protected Cell Company

Public Benefit Corporation

Other (Specify)

Single Member Disregarded Entity Partnership Corporation

S-Corporation

Cooperative

Trust

Check below how the Member will be taxed federally

Individual Sole Proprietorship

General Partnership/Joint Venture

Estate

Trust (Non-statutory)/Business Trust

Other (Specify how the Member is federally taxed)

10A100(P)(06-18) Page 2

Full Legal Name (First Middle Last)

Social Security Number (REQUIRED) FEIN (if Responsible Party is another business)

Driver’s License Number (if applicable) Driver’s License State of Issuance

Business Title Effective Date of Title

Residence Address

City State Zip Code

Telephone Number County (if in Kentucky)

( ) –

/ /

Full Legal Name (First Middle Last)

Social Security Number (REQUIRED) FEIN (if Responsible Party is another business)

Driver’s License Number (if applicable) Driver’s License State of Issuance

Business Title Effective Date of Title

Residence Address

City State Zip Code


( ) –

/ /

9. Primary Business Location 11. Accounting Period

( ) –

Calendar Year: Year Ending December 31st

Fiscal Year: Year Ending ___ ___ /___ ___ (mm/dd)

52/53 Week Calendar Year: December ____________________ (Day of week year ends)

52/53 Week Fiscal Year: _______________________________ (Month & day of week year ends)

12. Accounting Method

Cash Accrual

Street Address (DO NOT List a PO Box)

City State Zip Code


10. Business Operations are Primarily Home Based Web Based Office/Store Based Transient

See instructions regarding required responsible parties for your business structure

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SECTION C TELL US ABOUT YOUR BUSINESS OR ORGANIZATION (Must Be Completed)

10A100(P)(06-18) Page 3

Name (First Middle Last) Title Daytime Telephone Extension

E-mail: (By supplying your e-mail address you grant the Department of Revenue permission to contact you via e-mail.)

( ) –

17. Person to contact about this application:

18a. Describe the nature of your business activity in Kentucky, including any services provided.

_________________________________________________________________________________________________________________________ 18b. List products sold in Kentucky.

_________________________________________________________________________________________________________________________

The following questions will determine your need for an Employer’s Withholding Tax Account.

The following questions will determine your need for a Sales and Use Tax Account, the schedules you may need to file,

and/or your need for aTransient Room Tax Account,

Motor Vehicle Tire Fee Account,Commercial Mobile Radio Service (CMRS) Prepaid Service Charge Account,

Utility Gross Receipts License Tax Account, and/orTelecommunications Tax Account.

Yes No19. Do you have or will you hire employees to work in Kentucky within the next 6 months? ......................................................................

An employee is anyone to whom you pay wages, including part-time help and family members. Kentucky corporate officers receiving compensation other than dividends are also considered employees.

20. Do you wish to voluntarily withhold on Kentucky residents who work outside Kentucky? .....................................................................

21. Do you wish to voluntarily withhold on pension and retirement payments? ...........................................................................................

22. Will your business be registered to make charitable or other lawful gaming payouts in Kentucky and be required to withhold federal tax from those payouts? ...................................................................................................................................................................

If you answered Yes to any of questions 19 through 22, you must complete SECTION D.

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Sales and Use Tax Account Yes No23. Will you make retail and/or wholesale sales of tangible or digital property in Kentucky? ...................................................................... Examples: prepared food, internet sales, downloaded music and books (see instructions for more).

24. Will you install replacement parts for the repair or recondition of tangible property? ............................................................................ Examples: automotive repairs, computer or electronics repair, furniture repair (see instructions for more).

25. Will you produce, fabricate, process, print or imprint tangible property? ................................................................................................ Examples: sign making, window tinting, embroidery, screen printing, engraving (see instructions for more).

26. Will you charge for labor or services rendered in installing or applying tangible personal property, digital property, or service sold?

27. Will you provide any of the following services? (see instructions for more.)

CONTINUED ON NEXT PAGE

Yes No A. Landscaping services

B. Janitorial services

C. Small animal veterinary services

D. Pet care services

E. Industrial laundry services

F. Non-coin operated laundry and dry cleaning services

Yes No G. Linen supply services

H. Indoor skin tanning services

I. Non-medical diet and weight reducing services

J. Limousine services, with a driver provided

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Yes No A. Water utilities

B. Natural, artifical, or mixed gas utilities

C. Electricity

D. Sewer services

Yes No E. Communications services

F. Multichannel video programming services *(see instructions)

G. Direct broadcast satellite services *(see instructions)

If you answered Yes to any of questions 23 through 44 E, you must complete SECTION E.

If you answered Yes to any of questions 43 through 44 F, you must complete SECTION F.

If you answered Yes to any of questions 44 E through 44 G, you must complete SECTION G.

10A100(P)(06-18) Page 4

Transient Room Tax Account Yes No40. Will you rent temporary lodging to others? ................................................................................................................................................. Examples: hotel, motel, or inn (see instructions for more).

Motor Vehicle Tire Fee Account

41. Will you sell new tires for motor vehicles? ..................................................................................................................................................

Commercial Mobile Radio Service (CMRS) Prepaid Service Charge Account

42. Will you sell cellular phones with preloaded minutes, prepaid cellular phone cards, or recharge cellular phones and cards with minutes? .................................................................................................................................................................................................

Utility Gross Receipts License Tax Account and/or Telecommunications Tax Account

43. Were you approved for an Energy Direct Pay Authorization with a Utility Gross Receipts License Tax Exemption? ............................ Attach a copy of your official UGRLT Exemption Authorization.44. Will you sell any of the following?

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The following question will determine your need for a Consumer’s Use Tax Account.

Skip question 45 if you must complete Section E.

If you answered Yes to question 45, you must complete SECTION H.

Yes No45. Will you make purchases from out-of-state vendors and not pay Kentucky Sales or Use Tax to the seller on those purchases? ....... If you are a PROFESSIONAL SERVICE business or if your business will make a one-time purchase only, please see instructions for important additional details.

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Yes No28. Will you sell extended warranties? ...............................................................................................................................................................

29. Will you rent or lease tangible or digital property to others, including related companies? ...................................................................

30. Will you charge admissions, including initiation fees, monthly fees or membership fees for the use of a facility or participating in an event or activity? (see instructions for additional information.) ................................................................................

31. Are you a remote retailer selling tangible personal property or digital property delivered or trnasferred electronically to a purchaser in Kentucky? (see instructions for additional information.) ..............................................................................................

32. Are you a manufacturer’s agent soliciting orders for a nonresident seller not registered in Kentucky? ................................................

33. Are you a manufacturing fee processor or a contract miner operating in Kentucky? ..............................................................................

34. Are you bidding on a contract with Kentucky state government? .............................................................................................................

35. Are you an affiliate of a company who has been awarded a Kentucky state government contract? ......................................................

36. Will you rent campsites at campgrounds or recreational vehicle parks? ..................................................................................................

Sales and Use Tax Account Schedules

37. Will you receive receipts from the breeding of a stallion to a mare in Kentucky? ....................................................................................

38. Will you make sales of aviation jet fuel? ......................................................................................................................................................

39. Will you make sales of motor vehicles to residents of Arizona, California, Florida, Indiana, Massachusetts, Michigan, South Carolina, or Washington? ...............................................................................................................................................................................

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10A100(P)(06-18) Page 5

CONTINUE

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The following questions will determine your need for a Kentucky Nonresident Income Tax Withholding on Distributive Share Income Tax Account.

The following questions will determine your need for a Coal Severance/Processing Tax Account and/or a Coal Seller Purchaser Certificate ID#.

Yes No53. Is the business considered a pass-through entity as defined in KRS 141.010(26)? ...................................................................................

54. Does your pass-through entity have nonresident: Yes No A. Individual partner(s), shareholder(s), or member(s) receiving Kentucky distributive share income from your pass-through entity? ..............................................................................................................................................................................

“Individual" includes estates and trusts.

B. Corporate partner(s) or member(s) receiving Kentucky distributive share income from your pass-through entity? ...................

If you answered Yes to questions 54 A and/or 54 B, you must complete SECTION J.

If you answered Yes to question 53, you must answer questions 54 A and 54 B.

If you answered Yes to any of questions 55 through 57, you must complete SECTION K and SECTION E.

Yes No55. Will you mine coal to which you own or possess the mineral rights?.......................................................................................................

56. Will you purchase coal for the purpose of processing and resale, or do you process refuse coal? .......................................................

Processing means cleaning, breaking, sizing, dust allaying, treating to prevent freezing, or loading or unloading for any purpose.

57. Will you purchase and sell coal as a coal broker? .......................................................................................................................................

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The following questions will determine your need for a Corporation Income Tax Account and/or a Limited Liability Entity Tax Account.

If you answered Yes to any of questions 46 through 52, you must complete SECTION I.

If your answer to questions 13 and 14 was NOTSole Proprietorship, HCSR, Qualified Joint Venture, Estate, Government,

General Partnership taxed as a Partnership, or Joint Venture taxed as a Partnership, you must complete questions 46 through 52.

Yes No46. Are you organized under the laws of Kentucky with the Kentucky Secretary of State’s Office? ..............................................................

47. Will your business have its commercial domicile in Kentucky? .................................................................................................................

48. Will your business own or lease any real or tangible property in Kentucky? ...........................................................................................

49. Will your business have one or more individuals performing services in Kentucky? ..............................................................................

50. Will your business maintain an interest in a pass-through entity or derive income from Kentucky sources? ......................................

51. Will you direct activities toward Kentucky customers for the purpose of selling them goods and/or services? ...................................

52. Will your business own/lease any intangible property or receive payments from a related member as defined in KRS 141.205(1)(g) or an unrelated party for the use of intangible property in Kentucky such as royalties, franchise agreements, patents, trademarks, etc.? .................................................................................................................................................................................................................

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10A100(P)(06-18) Page 6

SECTION E SALES AND USE TAX ACCOUNT TRANSIENT ROOM TAX ACCOUNT

MOTOR VEHICLE TIRE FEE ACCOUNTCOMMERCIAL MOBILE RADIO SERVICE (CMRS) PREPAID SERVICE CHARGE ACCOUNT

Must be completed if you answered Yes to any of questions 23 through 44 E or any of questions 55 through 57.

65. Date sales began or will begin (REQUIRED)

66. Estimated gross monthly sales tax collected in Kentucky:

$0.00–$1,199.99 $1,200.00 or more

67. A. Does this business have additional locations in Kentucky other

than the Primary Business Location? Yes No

B. If Yes, attach a listing of all additional Kentucky locations. For each

location, the attachment should include: doing business as (DBA)

name, physical location address, phone number, date location was

opened, and a description of the location’s business activity.

/ / c/o or Attn.

Address

City State Zip Code

Mailing Telephone Number County (if in Kentucky)

( ) –

64. A. Has a Kentucky Sales and Use Tax Account already been assigned to this business? Yes No

B. If Yes, list the Sales and Use Tax Account Number

68. Sales and Use Tax returns should be mailed to:

Use the same address as your location address

Use the same address as _______________________ Tax Account

SECTION D EMPLOYER’S WITHHOLDING TAX ACCOUNT Must be completed if you answered Yes to any of questions 19 through 22.

58. A. Has a Kentucky Employer’s Withholding Tax Account already been assigned to this business? Yes No

B. If Yes, list the Employer’s Withholding Tax Account Number

59. Number of Kentucky employees ______________________________

60. Date wages/pensions first paid or will be paid (REQUIRED)

61 Estimated total annual tax withheld in Kentucky:

$0.00–$399.99 $2,000.00–$49,999.99

$400.00–$1,999.99 $50,000.00 or more

62. A. Is the withholding for your employees reported by a Common Paymaster or a Common Pay Agent? Yes No

Most payroll processors do NOT operate as Common Paymasters/Pay Agents. If using a payroll processor, check with them to determine if you should answer yes to the question above.

B. If Yes, attach a separate sheet listing which you use, Common Paymaster or Common Pay Agent, and provide their Business Name, FEIN, and Kentucky Employer’s Withholding Tax Account Number.

/ / c/o or Attn.

Address

City State Zip Code


( ) –

63. Employer’s Withholding Tax returns should be mailed to:


Use the same address as ______________________ Tax Account

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10A100(P)(06-18) Page 7

77. Date purchases began or will begin (REQUIRED)

/ / c/o or Attn.

Address

City State Zip Code


( ) –

76. A. Has a Consumer’s Use Tax Account already been assigned to this business? Yes No

B. If Yes, list the Consumer’s Use Tax Account Number

78. Consumer’s Use Tax returns should be mailed to:



SECTION H CONSUMER’S USE TAX ACCOUNT Must be completed if you answered Yes to question 45.

SECTION F UTILITY GROSS RECEIPTS LICENSE TAX ACCOUNT Must be completed if you answered Yes to any of questions 43 through 44 F.

69. A. Has a Kentucky Utility Gross Receipts License Tax Account already been assigned to this business? Yes No

B. If Yes, list the Utility Gross Receipts License Tax Account Number

70. Date sales of utilities began or will begin (REQUIRED)

71. Telephone Number

/ / Once the account for Utility Gross Receipts License Tax is assigned, use the website below to set up account for e-file.

http://revenue.ky.gov/Business/Utility-Gross-Receipts-License-Tax/Pages/default.aspx

(__________) __________ – ____________________

SECTION G TELECOMMUNICATIONS TAX ACCOUNT Must be completed if you answered Yes to any of questions 44 E through 44 G.

72. A. Has a Kentucky Telecommunications Tax Account already been assigned to this business? Yes No

B. If Yes, list the Telecommunications Tax Account Number

73. Does your organization have tangible personal property located within the Commonwealth of Kentucky? Yes No

74. Date sales of communications began or will begin (REQUIRED)

75. Telephone Number

/ / Once the account for Telecommunications Tax is assigned, use the website below to set up account for e-file.

http://revenue.ky.gov/Business/Telecommunications-Tax/Pages/default.aspx

(__________) __________ – ____________________

10A100(P)(06-18) Page 8

SECTION J KENTUCKY NONRESIDENT INCOME TAX WITHHOLDING ON DISTRIBUTIVE SHARE INCOME TAX ACCOUNT Must be completed if you answered Yes to question 54 A and/or B.

85. A. Has a Kentucky Nonresident Income Tax Withholding on Distributive Share Income Tax Account already been assigned to this business?

Yes No

B. If Yes, list the Kentucky Nonresident Income Tax Withholding on Distributive Share Income Tax Account Number

86. Date first nonresident corporation or individual became a

partner, member, or shareholder (REQUIRED)

87. A. Is your entity exempt from Kentucky Nonresident Income Tax Withholding on Distributive Share Income Tax under Kentucky law? Yes No

B. If Yes, see Exemption Table 2 in the instructions to provide the code for your Exemption Type.

__________________________________________________

/ /

c/o or Attn.

Address

City State Zip Code


( ) –

88. Nonresident Distributive Share Withholding Tax correspondence should be

mailed to:



84. Corporation Income and/or Limited Liability Entity Tax correspondence

should be mailed to:



/ /

SECTION I CORPORATION INCOME AND/OR LIMITED LIABILITY ENTITY TAX ACCOUNT Must be completed if you answered Yes to any of questions 46 through 52.

c/o or Attn.

Address

City State Zip Code


( ) –

79. A. Has a Corporation Income and/or Limited Liability Entity Tax Account already been assigned to this business? Yes No

B. If Yes, list the Corporation Income or Limited Liability Entity Tax Account Number

80. A. Is this entity treated federally as a division of a parent company

and not separately taxed as its own entity? Yes No

B. If Yes, select the division type below:

Qualified Subchapter S-corporation Subsidiary (QSUB)

Qualified Real Estate Investment Trust Subsidiary (QRS)

81. If an out-of-state entity, is your Kentucky activity limited to the mere

solicitation of the sale of tangible personal property and exempt from

Corporation Income tax due to Public Law 86-272? Yes No

82. If an out-of-state entity, date activity or receipt of pass through income

began or will begin in Kentucky

83. A. Is your entity exempt from Corporation Income Tax and/or Limited Liability Entity Tax under Kentucky law? Yes No

B. If Yes, see Exemption Table 1 in the instructions to provide the code for your Exemption Type. __________________________________________

C. If Political Organization selected above, are you required to file federal Form 1120-POL? Yes No

10A100(P)(06-18) Page 9

The Kentucky Department of Revenue does not discriminate on the basis of race, color, national origin, sex, age, religion, disability, sexual orientation, gender identity, veteran status, genetic information or ancestry in employment or the provision of services.

For assistance in completing the application, please call the Division of Registration at (502) 564–3306, Monday through Friday between the hours of

8:00 a.m. and 5:00 p.m., Eastern Time, or you may use the Telecommunications Device for the Deaf at (502) 564-3058.

SEND completed application to: KENTUCKY DEPARTMENT OF REVENUE

DIVISION OF REGISTRATION

P.O. BOX 299, STATION 20

FRANKFORT, KENTUCKY 40602–0299

FAX: 502–227–0772

E-MAIL: [email protected]

If you would like to register for Electronic Funds Transfer (EFT), visit the Kentucky Department of Revenue website at http://revenue.ky.gov.

This form does not include registration with the Secretary of State, Unemployment Insurance, or Workers’ Compensation Insurance. For assistance,

please contact those offices at the numbers below.

Secretary of State (502) 564–3490 Unemployment Insurance (502) 564–2272 Workers’ Compensation (502) 564–5550

IRS—FEIN (800) 829–4933

For assistance with other questions about starting a business in Kentucky, including special licensing and permitting requirements, business structure registration,

employer responsibilities, and business development resources, call the Business Information Clearinghouse at 1–800–626–2250 or visit the Kentucky Business

One Stop website at http://onestop.ky.gov.

SECTION K COAL SEVERANCE/PROCESSING TAX ACCOUNT and/or COAL SELLER/PURCHASER CERTIFICATE ID # Must be completed if you answered Yes to any of questions 55 through 57.

90. Date mining/processing or coal brokering operations began

or will begin (REQUIRED)

/ / c/o or Attn.

Address

City State Zip Code


( ) –

89. A. Has a Coal Severance Tax Account and/or a Coal Seller/Purchaser Certificate ID # already been assigned to this business? Yes No

B. If Yes, list the Coal Severance Tax Account Number

C. If Yes, list the Coal Seller/Purchaser Certificate ID Number

91. Coal Severance & Processing Tax returns should be mailed to:



The statements contained in this application and any accompanying schedules are hereby certified to be correct to the best knowledge and belief of the

undersigned who is duly authorized to sign this application.

Signature: __________________________________________________ Printed Name: _______________________________________________

Phone Number: ______________________________________________ Title: ______________________ Date: ____/____/______(mm/dd/yyyy)

IMPORTANT: THIS APPLICATION MUST BE SIGNED BELOW:

-'

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NJ-REG 3-2011

I* NO FEE REQUIRED* I

STATE OF NEW JERSEY DIVISION OF REVENUE

BUSINESS REGISTRATION APPLICATION Please read instructions carefully before filling out this form

ALL SECTIONS MUST BE FULLY COMPLETED

A. Please indicate the reason for your filing this application:

0 Original application for a new business 0 Moved previously registered business to new location (REG-C-L can be used in lieu of NJ-REG) 0 Amended application for an existing business

Reason(s) for amending application:---------------------------0 Application for an additional location of an existing registered business

MAIL TO: CLIENT REGISTRATION PO BOX 252 TRENTON, NJ 08646-0252

OVERNIGHT DELIVERY: CLIENT REGISTRATION 33 West State St 3rd FL TRENTON, NJ 08608

Hotline (609) 292-9292

0 Applying for a Business Registration Certificate 0 Employer of Domestic Household Employee(s) www. nj.gov/treasury /rev en u~

0 Withholding for Employee(s) residing in NJ (fiQ.Ldoing business or employingJ!l NJ)

B. FEIN# OR Soc. Sec.# of Owner

0 Check Box if "Applied for"

C. Name _________ m;~~;,;~~;Cc~~0UZL~~~~~~~~~~~;;~NQ-G;~;;~~~~;.;,~------------(If your business entity is a Owner or Partners)

D. TradeName _________________________________________________________________________________ ___

E. Business Location: (Do not use P.O. Box for Location Address)

Street------------------------

City---------------

Zip Code

(Give 9-digit Zip)

(See instructions for providing alternate addresses)

G. Beginning date for this business:

H. Type of ownership (check one): 0 NJ Corporation 0 Sole Proprietor

month

0 Partnership

F. Mailing Name and Address: (if different from business address)

Zip Code

________ (see instructions) 10/C_ year

0 Out-of-State Corporation 0 LLP 0 Other _______ _ 0 Limited Partnership 0 LLC ( 1 065 Filer) 0 LLC (1120 Filer) 0 LLC (Single Member) 0 S Corporation (You must complete page 41)

I. New Jersey Business Code (see instructions) 0 Domestic (Household Employer) FOR OFFICIAL USE ONLY

J. County I Municipality Code (see instructions) K. County DLN ------------------

L Will this business be SEASONAL? 0 Yes 0 No ( New Jersey only )

If YES- Circle months business will be open:

JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NOV DEC

M. If an ENTITY (Item C) complete the following:

Date of Incorporation:--.,.--month day

Fiscal month State of Incorporation year

NJ Business/Corp. #

Is this a Subsidiary of another corporation? 0 YES 0 NO lfYES,g~enameandFederniiD#~pa~nt ____________________________________________________________ ~

N. Standard Industrial Code (If known) 0. NAICS (If known)

P. Provide the following information for the owner, partners or responsible corporate officers. (If more space is needed, attach rider)

NAME (Last Name, First, Ml)

1 __ ~S~O~C~IA~L~S~E~C~U~R~ITY~~N~UM~BE~R~---r--------~H~O~M~E~A~D~D~R~E~S~S~------~ PERCENTOF TITLE (Street, City, State, Zip) OWNERSHIP

~ ~---------------------------~-----------------~--------------------~------~ :I: (f)

a:: w

~ ~-----------------------------+------------------------+-----------------------------+--------~ 0

BE SURE TO COMPLETE NEXT PAGE

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FEIN#: NAME: NJ-REG Each Question Must Be Answered Completely

1. a. Have you or will you be paying wages. salaries or commissions to employees working in New Jersey within the next 6 months? 0 Yes 0 No

Give date of first wage or salary payment I 1 ___ _

Month Day Year

If you answered "No" to question 1.a., please be aware that if you begin paying wages you are required to notify the Client Registration Bureau

at PO Box 252, Trenton NJ 08646-0252, or phone (609)-292-9292.

b. Give date of hiring first NJ employee: I ____ 1 ___ _ Month Day Year

c. Date cumulative gross payroll exceeds $1,000 --Tr-~~~--~~--~--~~--Month Day Year

d. Will you be paying wages, salaries or commissions to New Jersey residents working outside New Jersey?

e. Will you be the payer of pension or annuity income to New Jersey residents?

f. Will you be holding legalized games of chance in New Jersey (as defined in Chapter 47 Rules of Legalized Games of Chance) where proceeds from any one prize exceed $1 ,000?

g. Is this business a PEO (Employee Leasing Company)? (If yes, see page 6)

o Yes 0 No

0 Yes 0 No

o Yes 0 No

0 Yes o No

2. Did you acquire 0 Substantially all the assets; 0 Trade or business; 0 Employees; of any previous employing units? 0 Yes 0 No If answer is "No", go to question 4. If answer is "Yes", indicate by a check whether 0 in whole or 0 in part, and list business name, address and registration number of predecessor or acquired unit and the date business was acquired by you. (If more than one, list separately. Continue on separate sheet if necessary.)

Name of Acquired Unit----------------N.J. Employer ID

Address _______________________ ___

Date Acquired

ACQUIRED

0 Assets

0 Trade or Business 0 Employees

PERCENTAGE ACQUIRED

_______ %

_______ %

_______ %

3. Subject to certain regulations, the law provides for the transfer of the predecessor's employment experience to a successor where the whole of a business is acquired from a subject predecessor employer. The transfer of the employment experience is required by law.

Are the predecessor and successor units owned or controlled by the same interests? .

4. Is your employment agricultural? ...

5. Is your employment household?

0 Yes

0 Yes

0 Yes

o No

0 No

0 No

a. If yes. please indicate the date in the calendar quarter in which gross cash wages totaled $1,000 or more I 1---:-:---Month Day Year

6. Are you a 501 (c)(3) organization? . 0 Yes 0 No If "Yes", to apply for sales tax exemption, obtain form REG-1 Eat http://www.state.nj.usltreasuryltaxationlpdflother_formslsaleslreg1 e.pdf

7. Were you subject to the Federal Unemployment Tax Act (FUTA) in the current or preceding calendar year? 0 Yes o No

(See instruction sheet for explanation of FUTA) If "Yes", indicate year:------------------------

8. a. Does this employing unit claim exemption from liability for contributions under the Unemployment Compensation Law of New Jersey? 0 Yes 0 No

If "Yes," please state reason. (Use additional sheets if necessary.)-------------------------------------

b. If exemption from the mandatory provisions of the Unemployment Compensation Law of New Jersey is claimed, does this employing unit wish to voluntarily elect to become subject to its provisions for a period of not less than two complete calendar years?

9 Type of business 0 1 Manufacturer 0 2. Service 0 3 Wholesale

0 4. Construction 0 5. Retail 0 6 Government

Principal product or service in New Jersey only

Type of Activity in New Jersey only

10. List below each place of business and each class of industry in New Jersey, even though you may have only one place of business or engage in only one class of industry.

a. Do you have more than one employing facility in New Jersey

NJ WORK LOCATIONS (Physical location, not mailing address) NATURE OF BUSINESS (See Instructions)

Street Address, City, Zip Code County NAICS Code

(Continue on separate sheet, 1f necessary)

BE SURE TO COMPLETE NEXT PAGE - 18-

Principal Product or Service

Complete Description %

DYes o No

0 Yes 0 No

No. of Workers at Each Location

and/in Each Class of Industry

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FEIN: NAME:

Each Question Must Be Answered Completely 11. a. Will you collect New Jersey Sales Tax and/or pay Use Tax?

GIVE EXACT DATE YOU EXPECT TO MAKE FIRST SALE --;;;;:=:--.!--~:-:--...!-""""'r::-:-::---

b. Will you need to make exempt purchases for your inventory or to produce your product?

c. Is your business located in (check applicable box(es)): 0 Atlantic City 0 Salem County

0 North Wildwood 0 Wildwood Crest 0 Wildwood d. Do you have more than one location in New Jersey that collects New Jersey Sales Tax? (If yes, see instructions) ..... .

e. Do you, in the regular course of business, sell, store, deliver or transport natural gas or electricity to users or customers in this state whether by mains, lines or pipes located within this State or by any other means of delivery?

12. Do you intend to sell cigarettes? . Note: If yes, complete the REG-L form on page 45 in this booklet and return with your completed NJ-REG.

To obtain a cigarette retail or vending machine license complete the form CM-1 00 on page 48. 13. a. Are you a distributor or wholesaler of tobacco products other than cigarettes?

b. Do you purchase tobacco products other than cigarettes from outside the State of New Jersey? .

14. Are you a manufacturer, wholesaler, distributor or retailer of "litter-generating products"? See instructions for retailer liability and definition of litter-generating products.

15. Are you an owner or operator of a sanitary landfill facility in New Jersey? .. IF YES, indicate D.E.P. Facility# and type (See instructions)----------------

16. a. Do you operate a facility that has the total combined capacity to store 200,000 gallons or more of petroleum products?

b. Do you operate a facility that has the total combined capacity to store 20,000 gallons (equals 167,043 pounds) of hazardous chemicals?

c. Do you store petroleum products or hazardous chemicals at a public storage terminal? . Name of terminal _______________________________ _

NJ-REG

0 Yes 0 No

0 Yes 0 No

0 Yes 0 No

0 Yes 0 No

0 Yes 0 No

0 Yes 0 No

0 Yes 0 No

0 Yes 0 No

0 Yes 0 No

0 Yes 0 No

0 Yes 0 No

0 Yes 0 No

17. a. Will you be involved with the sale petroleum products? 0 Yes 0 No Note: If yes, complete the REG-L form in this booklet and return with your completed NJ-REG. You will be sent a motor

fuel licence application (MFA-1) or you can download this application at www.state.nj.us/treasury/taxation/prntmf.shtml

b. Will your company be engaged in the refining and/or distributing of petroleum products for distribution in this State or the importing of petroleum products into New Jersey for consumption in New Jersey? ......................... .

c. Will your business activity require you to issue a Direct Payment Permit in lieu of payment of the Petroleum Products Gross Receipts Tax on your purchases of petroleum products?

18. Will you be providing goods and services as a direct contractor or subcontractor to the state, other public agencies including local governments, colleges and universities and school boards, or to casino licensees?

19. Will you be engaged in the business of renting motor vehicles for the transportation of persons or non-commercial freight? . . . . . . . . . . . ....... .

20. Is your business a hotel, motel, bed & breakfast or similar facility and located in the State of New Jersey?

21. Will this business be operating in the Sports and Entertament District of Millville NJ ? .. If yes, will the business be engaged.l!:! obtaining gross receipts from any of the following (Circle all that apply if "Yes")

0 Yes 0 No

0 Yes 0 No

0 Yes 0 No

0 Yes 0 No

0 Yes 0 No

0 Yes 0 No

§!Sales, rental or leases of tangible personal property J?.. Sales of food & drink?£· Charges of admission £LRental charges for hotel occupanciesl

22. Do you make retail sales of new motor vehicle tires, or sell or lease motor vehicles? ..

23. Do you provide "cosmetic medical procedures" or goods or occupancies directly associated with such procedures? (See description of Cosmetic Procedures Gross Receipts Tax in the list of Taxes of the State of New Jersey, page 5.) Type of Business. _____________________ _

24. Do you sell voice grade access telecommunications or mobile telecommunications to a customer with a primary place of use in this State?

25. Contact Information: Person---------------------- Title:

Daytime Phone: ( Ext. __ _ E-mail address:

Signature of Owner, Partner or Officer:

Title Date:

NO FEE IS REQUIRED TO FILE THIS FORM

0 Yes 0 No

0 Yes 0 No

0 Yes 0 No

IF YOU ARE A SOLE PROPRIETOR OR A PARTNERSHIP WITHOUT EMPLOYEES -STOP HERE-IF YOU HAVE EMPLOYEES PROCEED TO THE STATE OF NJ NEW HIRE REPORTING FORM ON PAGE 29

IF YOU ARE FORMING A CORPORATION, LIMITED LIABILITY COMPANY, LIMITED PARTNERSHIP, OR A LIMITED LIABILITY PARTNERSHIP YOU MUST CONTINUE ANSWERING APPLICABLE QUESTIONS ON PAGES 23 AND 24

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STATE OF NEW JERSEYDIVISION OF REVENUE

PUBLIC RECORDS FILING FOR NEW BUSINESS ENTITYFill out all information below INCLUDING INFORMATION FOR ITEM 11, and sign in the space provided. Please note that once filed,this form constitutes your original certificate of incorporation/formation/registration/authority, and the information contained in the filedform is considered public. Refer to the instructions for delivery/return options, filing fees and field-by-field requirements. Remember toremit the appropriate fee amount. Use attachments if more space is required for any field, or if you wish to add articles for the public record.

1. Business Name:

2. Type of Business Entity: ___ ___ ___ 3. Business Purpose :(See Instructions for Codes, Page 21, Item 2) (See Instructions, , Item 3)

4. Stock (Domestic Corporations only; LLCs and Non-Profit leave blank): 5. Duration (If Indefinite or Perpetual, leave blank):

6. State of Formation/Incorporation (Foreign Entities Only): 7. Date of Formation/Incorporation (Foreign Entities Only):

8. Contact Information:Registered Agent Name: _____________________________________________________________________________

Registered Office: Main Business or Principal Business Address:(Must be a New Jersey street address)

Street ____________________________________________________ Street _________________________________________________

City __________________________________ Zip _______________ City _______________________State_________Zip ___________

9. Management (Domestic Corporations and Limited Partnerships Only)• For-Profit and Professional Corporations list initial Board of Directors, minimum of 1;• Domestic Non-Profits list Board of Trustees, minimum of 3;• Limited Partnerships list all General Partners.

Name Street Address City State Zip_______________________________ ___________________________________ ______________________ ________ ________________

_______________________________ ___________________________________ ______________________ ________ ________________

_______________________________ ___________________________________ ______________________ ________ ________________

The signatures below certify that the business entity has complied with all applicable filing requirements pursuant to the laws of the State of New Jersey.

10. Incorporators (Domestic Corporations Only, minimum of 1)

Name Street Address City State Zip

_______________________________ ___________________________________ ______________________ ________ ________________

_______________________________ ___________________________________ ______________________ ________ ________________

Signature(s) for the Public Record (See instructions for Information on Signature Requirements)

Signature Name Title Date

________________________________________ ______________________________ ________________________ ___________________

________________________________________ ______________________________ ________________________ ___________________

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Mail to: PO Box 308Trenton, NJ 08646

“FEE REQUIRED”

Overnight to: 33 West State St.5th FloorTrenton, NJ 08608-1214

11. Additional Entity - Specific Information

A. Domestic Non-Profit Corporations (Title 15A) - For IRS exemption considerations, see instructions.1a. The corporation shall have members: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

If yes, qualification shall be:As set forth in the by-laws or, As set forth herein:

1b.The rights and limitations of the different classes of members shall be:As set forth in the by-laws or, As set forth herein:

2. The method of electing the trustees shall be:As set forth in the by-laws or, As set forth herein:

3. The method of distribution of assets shall be:As set forth in the by-laws or, As set forth herein:

B. Foreign Corporations - Profit, Non-Profit and Foreign Legal Professional (Titles 14A and 15A)Attach a certificate of good standing/existence from the state of incorporation not greater than 30 days old to this form.

C. Limited Partnerships (Title 42:2A)1. Set forth the aggregate amount of cash and a description and statement of the agreed value

of other property or services contributed (or to be contributed in the future) by all partners:

2. Do the limited partners have the power to grant the right to become a limited partner to anassignee of any part of their partnership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NoIf yes, list the terms/conditions of that power:

3. Do the limited partners have the right to receive distributions from a partner which includes areturn of all or any part of the partner’s contributions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NoIf yes, list the applicable terms:

4. Do the general partners have the right to make distributions to a partner which includes areturn of all or any part of the partner’s contributions? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes NoIf yes, list the applicable terms:

5. What are the rights of the remaining general partners to continue the business in the eventthat a general partner withdraws? List below:

D. Foreign Limited Partnerships (Title 42:2A)Set forth the aggregate amount of cash and a description and statement of the agreed value of other property or servicescontributed (or to be contributed in the future) by all partners:

Public Records Filing for New Business Entity (continued)

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INSTRUCTIONS FOR BUSINESS ENTITY PUBLIC RECORD FILING

GENERAL INSTRUCTIONS AND DELIVERY/RETURN OPTIONS

1. Type or machine print all Public Records Filing forms, and submit with the correct FEE amount. (See FEE schedule on page 22).

2. Choose a delivery/return option:

a. R e g u l a r m a i l - If you are sending work in via regular mail, use the correct address:

New Jersey Department of the Treasury Division of Revenue & Enterprise Services/Corporate Filing Unit PO Box 308 Trenton, NJ 08646-0308

All processed mail-in work will be returned via regular mail. Providing a self-addressed return envelope will speed processing. Otherwise, on a cover letter, indicate the return address if other than the registered office of the business entity.

b. Expedited/Over-the-Counter - If you are expediting a filing (8.5 business hour processing), make sure that you deliver over- the- counter to: 33 W. State Street, 5th Floor, Trenton, NJ 08608- 1001, or have a courier/express mail service deliver to this address. Do not use USPS overnight delivery. Be sure to provide instructions as to how the filing is to be sent back to you: regular mail; front desk pick-up at 33 W. State Street; or delivery by courier/express mail. If you use a courier or express mail service for return delivery, be sure to provide a return package and completed air bill showing your name or company name (in the “to” and “from” blocks) and your courier account number.

Notes: Use an acceptable payment method for mail and over-the- counter work:

• Check or money order payable to the Treasurer, State of NJ; • Credit card -MASTERCARD/VISA or DISCOVER (provide card

number, expiration date and name/address of card holder); • Depository account as assigned by the Treasurer; or • Cash.

For over-the-counter AND mail-in submissions, remember to provide the required number of copies of the Public Record Filing. Filings for for-profit entities are submitted in duplicate and nonprofit filings are done in triplicate.

c. Facsimile Filing Service (FFS) - Transmit your filings to (609) 984-6851. You may request 8.5 business hour processing (EXPEDITED SERVICE), or same business day processing (SAME DAY SERVICE). Processing includes document review, fee accounting and acknowledgment turnaround.

Payment Methods - You may pay for services via credit card (Master Card/Visa, Discover and American Express) or depository account (one payment method per request).

Delivery/Turnaround - Barring difficulties beyond the Division of Revenue and Enterprise Services control, including those that affect the Division’s data communication or data processing systems, all EXPEDITED requests delivered to the FFS workstation between 8:30 a.m. and 5:00 p.m. on workdays will be processed and returned within 8.5 business hours, while SAME DAY requests delivered by 12:00 noon on work days will be processed by 5:00 p.m. the same day. Requests received during off hours, week- ends or holidays will be processed on the next work day, in 8.5 business hours. In the event of down time, upon system recovery, requests will be processed in receipt date/time order.

Cover Sheet - with your transmission, send a cover sheet entitled New Jersey Department of the Treasury Division of Revenue and Enterprise Services Facsimile Filing Service Request

The cover sheet must include work request details: Name of firm or individual transmitting the service request; date of submission; depository account number or credit card number with expiration date; description of service requested e.g., “Certificate o f

Incorporation”; business name associated with the filing (proposed name for a new business entity); desired service level (EXPEDITED or SAME DAY); total number of pages in the request transmission, including cover sheet; and fax back number.

Note: The Division of Revenue and Enterprises Services will accept one filing per FFS. Requests lacking cover sheets or required cover sheet information may be rejected. Requests that do not contain a fax back number will not be processed. Also, if a service level is not specified, the Division of Revenue will assume that the request is for EXPEDITED service.

The Division of Revenue and Enterprise Services will make three attempts to transmit to the fax back number you provide. If the transmissions are unsuccessful, the Division of Revenue will send acknowledgments of completed filings to the registered office of the business entity Involved via regular mail; or hold rejections in a pending file for two weeks, and dispose of the material thereafter.

Receiving Processed Work Back - For accepted work, the Division of Revenue and Enterprise Services will enter your Public Records Filing and Consolidated Registration application, and fax back an FFS Customer Transmittal with a copy of the approved Public Records Filing form stamped “FILED”. For rejected work, the Division will fax a FFS Customer Transmittal and Rejection Notice. If your submission is rejected, correct all defects and resubmit your filing as a new FFS request.

PAGE 23 INSTRUCTIONS

LINE BY LINE REQUIREMENTS FOR Public Records FILING Item 1 Business Name - Enter a name followed by an acceptable designator indicating the type of business entity--for example: Inc., Corp., Corporation, Ltd., Co., or Company for a corporation; LTD Liability Co., LTD Liability Company, Limited Liability Co., Limited Liability Company or L.L.C. for a Limited Liability Company; Limited Partnership or L.P. for a Limited Partnership; Limited Liability Partnership or L.L.P. for a Limited Liability Partnership.

Note: The Division will add an appropriate designator

if none is provided.

Remember that the name must be distinguishable from other names on the State’s data base. The Division of Revenue and Enterprises Services will check the proposed name for availability as part of the filing review process. If desired, you can reserve/register a name prior to submitting your filing by obtaining a reservation/registration. For information on name availability and reservation/registration services and fees, visit the Division’s Web site at http://www.state.nj.us/njbgs or call (609) 292-9292 Monday - Friday, 8:30 a.m. - 4:30 p.m.

Item 2 Type of Business Entity - Enter the two or three letter codes that corresponds with the type of business you are forming/registering:

Statutory Authority Entity Type Type Code

Title 14A Domestic Profit DP

For-Profit Corp. Domestic Professional PA Foreign Profit FR (Incl. Foreign Professional Corp.) Foreign Profit DBA “Doing Business As”

Title 15A Domestic Non-Profit NP Non-Profit�Corp. Foreign Non-Profit NF

Title 42:2C Domestic LLC LLC Limited Liability Co. Foreign LLC FLC

Title 42:2A Domestic LP LP Limited Partnership Foreign LP LF

Title 42 Limited Liability Domestic LLP LLP Partnership Foreign LLP FLP

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Item 3 Business Purpose - Provide a brief description of the business purpose for the public record. If the business is a domestic for- profit corporation, you may leave this field blank and thereby rely on the general purpose clause provided in N.J.S.A. 14A: “The purpose for which this corporation is organized is(are) to engage in any activity within the purposes for which corporations may be organized under N.J.S.A. 14A:1-1 et seq.”

Item 4 Stock - Domestic for-profit corporations only, list total shares.

Item 5 Duration - List the duration of the entity. If the duration is indefinite

or perpetual, leave the field blank.

Item 6 State of Formation/Incorporation- Foreign entities only, list home state.

Item 7 Date of Formation/Incorporation - Foreign entities only, list the

date of incorporation/formation in home state.

Item 8 Contact Information - Provide the following information: a) Registered Agent - Enter one agent only. The agent may be

an individual or a corporation duly registered, and in good standing with the State Treasurer.

b) Registered Office -Provide a New Jersey street address. A PO Box may be used only if the street address is listed as well.

c) Main Business Address - List the main business address.

Item 9 Management - For profit and professional corporations list initial Board of Directors, minimum of 1; domestic non-profits list Board of Trustees, minimum of 3; limited partnerships list all General Partners.

Item 10 Incorporators - Domestic profit, professional and non-profit corporations only, list incorporators, minimum of 1.

Signature Requirements for Public Records Filing: The incorporator(s) and only the incorporator(s) may sign domestic profit, professional and non-profit corporate filings. Only the president, VP or Chief Executive Officer may sign foreign corporate filings. ALL general partners must sign limited partnership filings. ANY authorized representative may sign domestic or foreign limited liability company filings, while any authorized partner may sign domestic or foreign limited liability partnership filings. PAGE 24 INSTRUCTIONS

Item 11 Provide additional “Entity-Specific” information as applicable.

Nonprofit corporations wanting Federal IRC section 501(c)(3) status are

advised to consult the IRS concerning IRS required wording. The IRS

telephone number is 1-877-829-5500, and the website is at www.irs.gov.

CHECKLIST FOR PUBLIC RECORDS FILING

¨ Completed and signed Public Records Filing (pages 23 and 24) (Note: Use appropriate envelope supplied - P.O. Box 308) ¨ Completed and signed Business Registration Application (pages 17-19) (NOTE: Use appropriate envelope

supplied-PO Box 252). ¨ Filing fee using an acceptable payment method. ¨ Transmittal letter or service request sheet with instruction for returning completed work (mail and over-the-counter requests) ¨ Completed and signed CBT-2553 (S Corporation Election) if applicable ¨ Cover sheet listing work request details (FAX Filing Requests)

CHECKLIST FOR BUSINESS REGISTRATION APPLICATIONS

¨ Completed and signed Registration Application (pages 17-19) ¨ Completed and signed NJ-REG-L (Cigarette and Motor Fuel Wholesalers/Distributors/Manufacturers only) or CM-100 (Cigarette and Motor Fuel Retailers only, if applicable). ¨ Completed and signed CBT-2553 (S corporation Election) if applicable

Delivery Options for: Public Records Filings: Business Registration Application: Mail: PO Box 308, Trenton, NJ 08646 Mail: PO Box 252, Trenton, NJ 08646-0252 Over-The-Counter:

Phone:

33 W. State Street, 5th Floor Trenton, NJ 08608-1214 (609) 292-9292

Overnight:FAX:

33 W. State St, 5th Floor, Trenton, NJ 08611(609) 292-4291

FEE SCHEDULE (Revised 7/1/02)

FFS FEES

• Each EXPEDITED FFS request is subject to a $15 fee, plus $1.00 per page fee for all accepted filings that are FAXED back for all Title 14A, Title 15A, and LP transactions. For LLCs and LLPs, each EXPEDITED FFS request is subject to a $25 fee, plus $1.00 per page fee for all accepted filings that are FAXED back.

• Each SAME DAY FFS request is subject to a $50 fee, plus a $1.00 per page fee, for all accepted filings that are FAXED back.

• These fees are in addition to the basic statutory fees associated with the filing itself.

• We also offer a one & two hour expedited service. The fees per filing are $1,000 and $500 respectively

BASIC FILING FEES

• Filing fee for all domestic entities, except non-profits, is $125 per filing; non-profit filing fee is $75 per filing.

• Filing fee for all foreign entities is $125 per filing.

SERVICE FEES AND OTHER OPTIONAL FEES (All added to basic filing fee, if selected.)

• Expediting Service Fee (8.5 business hours) is $15 per filing request for Title 14A, Title 15A and LP transactions.

• Expediting Service Fee (8.5 business hours) is $25 per filing request for LLCs and LLPs.

• Same Day Fee is $50 per filing request.

• Alternate Name Fee is $50 for each name. • FAX Page Transmission Fee is $1.00 per page for all filings that are FAXED back.

• Certified Copies of Accepted Filings are $25 for each filed entity.

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