Free Form CG-100-P-I - New York

New York State Department of Taxation and Finance

Instructions for Form CG-100-P
Personal Questionnaire
Article 20 of Tax Law

CG-100-P-I (3/06)

Who must file this form
A separate Personal Questionnaire is required for each controlling person of an applicant for license as a cigarette agent, a cigarette wholesaler, a tobacco products wholesaler, or for appointment as a tobacco products distributor. For purposes of this form, the term controlling person means any person who is an officer, director, or partner (or, in the case of a limited liability company, an officer, member, or a person having, with respect to such limited liability company, authority analogous to that of a corporate officer or director) of an applicant for an agent or wholesale dealer license under Article 20 of the Tax Law; or, if the applicant is a corporation, a shareholder who directly or indirectly owns more than 10% of the number of shares of voting stock of such corporation. It also includes persons who do or will exercise authority within the business comparable to the authority normally exercised by corporate officers, regardless of the form of business organization or lack of actual title. Personal Questionnaires may be submitted separately from the application for registration if the controlling person desires confidentiality. Read the instructions carefully. An application for a license cannot be processed until all of the required attachments are submitted. Item 1 -- Enter the exact legal name and federal employer identification number (FEIN) as listed on the application for license. Item 2 -- Enter your name, social security number, date of birth, telephone number, street address of current residence (PO box is not acceptable), and number of years at that address. Item 3 -- List all other addresses where you have lived during the past 10 years. Item 4(a) -- Enter your title(s), if any, with the applicant listed in item 1. Item 4(c) -- Check all boxes that identify your business activities. List any other duties that you have regarding your participation in significant business decisions, such as: · supervising the preparation of tax returns and insuring remittance of tax; · authority for management of business; · knowledge and control over financial affairs; · authority to pay or direct payment of creditors; · responsibility for maintaining/managing business records; · the authority to deal with the business' tax accountant or tax counsel; · authority to negotiate with the Tax Department or to sign any of the following: tax returns, consents extending

periods of limitation, power of attorney, audit method election agreements, consents fixing tax (for example, Statement of Proposed Audit Adjustment), installment payment agreements; · responsibility for handling business receipts; · authority to negotiate loans/borrow money for business or guaranteeing of business loans; · authority to hire or fire employees. Item 5 -- List any aliases or names (including maiden) used or formerly used by the person listed in item 2. Item 6 -- Provide all required information for the person listed in item 2. Item 7 -- List name, address, telephone number, and social security number of spouse (if married or separated). Item 8 -- Complete all the required information regarding your present and previous employment for the past 10 years. Item 9 -- If you are planning on taking an active role in the operation of the applicant listed in item 1, provide a schedule of the hours that will be devoted to the operation of the business. Item 10 -- If Yes, complete all of the required boxes for each entity. Attach additional sheets if necessary. Item 11 -- Are you, or have you been, an owner of 10% or more of the voting stock of any other corporation; or an officer, director, or partner of any other business other than the one for which you are applying? If Yes, complete all of the required boxes for each entity. Attach additional sheets if necessary. Item 12 -- If Yes, provide the name and address of applicant, date of filing, and disposition. If the application was refused, suspended, or revoked, provide a complete description of the events surrounding the refusal, suspension, revocation, and/or cancellation. Item 13 -- Check Yes only if you filed both a New York State and federal personal income tax return for each of the past five years. If you check No, enclose a copy of your federal return for any year that you did not file a New York State return. If you were not required to file either a New York State or a federal personal income tax return, enclose an explanation of the reason that no return was due and how you supported yourself for the years you were not required to file. Item 15(b) -- Include crimes committed in New York State and other states or countries. You may exclude traffic violations of the vehicle and traffic laws. Item 16(b) -- Include crimes pending in New York State and other states or countries. You may exclude traffic violations of the vehicle and traffic laws.

CG-100-P-I (3/06) (back)

Item 17 -- If Yes, provide details including: type of bankruptcy (Chapter 7, 11, 13, etc.), filing date, disposition (approved, dismissed, etc.), disposition date, jurisdiction. Item 18 -- Answer both (a) and (b) regarding your spouse (if applicable). If you answered Yes to either (a) or (b), your spouse must complete a separate personal questionnaire. Item 19 -- Provide a listing of any assets that you have contributed or will be contributing to this business. All items must be listed at current fair market value.

paper, and be glossy and not retouched. The photo should show a three-quarter frontal profile showing the right side of your face, with your right ear visible and with your head bare (unless you are wearing a headdress as required by a religious order of which you are a member). The photos should be no smaller than 2 x 2 inches, with the distance from the top of the head to just below the chin about 1¼ inches. Lightly print your social security number on the back of each photo with a pencil. -- Completed fingerprint card along with a money order in the amount of $75.00 payable to the Division of Criminal Justice Services (DCJS). (The DCJS will only accept money orders.) An application for license cannot be processed until all required attachments are submitted.

Required attachments:
-- Proof of U.S. citizenship or eligibility to obtain employment in the United States. Such proof must consist of original or certified copies of birth certificate, permanent resident's visa (green card), or valid work visa. -- Photocopy of a driver's license or non-driver government issued ID. --Two identical, natural color photographs of yourself taken within 30 days of filing this application. The photos must have a white background, be unmounted, printed on thin

Need help?
Internet access: www.nystax.gov (for information, forms, and publications) Fax-on-demand forms: Forms are available 24 hours a day, 7 days a week. 1 800 748-3676 Telephone assistance is available from 8:00 A.M. to 5:00 P.M. (eastern time), Monday through Friday. To order forms and publications: Business Tax Information Center: From areas outside the U.S. and outside Canada: 1 800 462-8100 1 800 972-1233 (518) 485-6800 Hotline for the hearing and speech impaired: If you have access to a telecommunications device for the deaf (TDD), contact us at 1 800 634-2110. If you do not own a TDD, check with independent living centers or community action programs to find out where machines are available for public use. Persons with disabilities: In compliance with the Americans with Disabilities Act, we will ensure that our lobbies, offices, meeting rooms, and other facilities are accessible to persons with disabilities. If you have questions about special accommodations for persons with disabilities, please call 1 800 972-1233.