Free Form CG-100-P - New York

New York State Department of Taxation and Finance

Personal Questionnaire
Article 20 of the Tax Law
Notice to individuals completing this form:
You may return the completed form to the NYS Department of Taxation and Finance in either of two ways: ­ by giving it to the applicant for inclusion with the license application form; or ­ by mailing directly to the Department at the following address: NEW YORK STATE TAX DEPARTMENT TTTB - REGISTRATION AND BOND UNIT WA HARRIMAN CAMPUS ALBANY NY 12227 Please print or type.

CG-100-P
(3/06)

Answer all questions. Indicate N/A if not applicable. If more space is needed, attach additional pages, clearly indicating the question to which the answer applies. Unanswered questions will delay the processing of this application.

1. 2.

Legal name of applicant for license Your name Home address Street City Social security number State

Federal employer identification number (FEIN) Date of birth ZIP code Home telephone number ( ) Years at this address

3.

If less than 10 years at current home address, please list former addresses for the past 10 years. Street City State ZIP code From (mo./yr.) To (mo./yr.)

4. (a) Title/position or relationship to applicant (b) Briefly describe your role and authority within the applicant's business.

(c) Check appropriate box(es) for each authority you do or will have. Signing checks on the company's bank account Signing the business' tax returns Paying creditors Making the final decision on which bills are to be paid Other 5. Have you ever been known by any other name(s)? Yes If Yes, State each name (including maiden name), social security number, and dates used. No Conducting the business' general financial affairs Filing returns or paying taxes imposed Complying with any other requirement of the Tax Law Ordering, receiving, or picking up cigarette stamps

6. Height
(ft./in.)

Weight
(lbs.)

(circleone) F M

Sex

Eye color

Hair color

(circleone)

Married

Country of birth U.S. Citizen

(If No, state registration number or visa type)

Yes

No

yes / no

Attach additional sheets as needed. Please include the item number referenced on additional sheets.

Page 2 of 4 CG-100-P (3/06) 7. If you indicated married in item 6, complete the following: Name of spouse (includingmaidenname) List any other names that spouse has been known by Home address (ifdifferentthanitem2above)

Social security number of spouse Home telephone number ( )

8. From

Your employment/occupation record for the past 10 years
(mo./yr.)

(mo./yr.)

To

Employed by

City, State

Occupation

9.

How many hours per week do you plan on devoting to this business? Will you engage in any business or occupation other than that of the applicant? ........................ If Yes, indicate the total weekly hours that will be devoted to other business

Yes

No

10.

Have you ever: ­ owned or controlled, directly or indirectly, more than 10% of the voting stock of a business other than the applicant listed in item 1 or ­ been an officer, director, sole proprietor, or partner of a business other than the applicant listed in item 1? Yes (completebelow)
Name of other business Address (number,street,city,state,ZIPcode) Name of other business Address (number,street,city,state,ZIPcode) FEIN

No
FEIN

11.

Do you have any interest, directly or indirectly, (other than through ownership of publicly traded securities) in any premises or business where any cigarettes or tobacco products are manufactured, transported or sold? Interest includes ownership, directorship, mortgage or lien on loans to, or ownership of any real or personal property, or by any other means employed by such company, including loans. Yes (completebelow)
Type of business

No
Date began (mo./yr.) Nature of interest Date acquired (mo./yr.)

Business name

Address of business

FEIN

Attach additional sheets as needed. Please include the item number referenced on additional sheets.

CG-100-P (3/06) Page 3 of 4 12. (a) Other than as shown in items 1 or 10, have you ever personally applied for or held in any state, city or country a license or permit to traffic in cigarettes or tobacco products? Yes No

(b) Has any business in which you were a controllingperson (as defined in item 20) ever applied for or held in any state, city or country a license or permit to traffic in cigarettes or tobacco products? Yes No

(c) If you answered Yes,to 12(a) or (b), state the name of the applicant, address of premises, date of filing and disposition.

13.

Have you (and your spouse, if married) filed both federal and New York State personal income tax returns for each of the past five calendar years? Yes No If Yes,please indicate the social security number and name on the return. If No, explain any year that no returns were filed; include copies of federal returns for each year it was filed when a New York State return was not filed.

14.

Do you or your spouse have a liability for a tax imposed by or pursuant to the authority of the New York State Tax Law, or for the City of New York or City of Yonkers earnings tax on nonresidents, that has been finally determined to be due and has not been paid in full? Yes (completebelow)
Person's name

No
Type of tax Amount due Assessment number Assessment date

15. (a) Have you ever been convicted (including pleas of guilty or no contest) of any felony or of any other crime or offense of any 15. (a) kind except violations of the vehicle and traffic laws? (b) If Yes, state date of conviction and crime or offense involved. In each case a CertificateofDisposition or a Certificateof Conviction from the court clerk must be attached.

Yes

No

(b) Crime or offense and date

16. (a) Are there any arrests, indictments, or summonses (except for violations of the vehicle and traffic laws) pending against you? (b) If Yes, state date thereof and crime or offense charged.

16. (a)

Yes

No

(b) Crime or offense and date

17.

Have you or any entity in which you are or were a controllingperson (as defined in item 20) ever filed a petition in bankruptcy or been adjudged bankrupt or made an assignment for the benefit of creditors? If Yes,provide details. Yes No

If you indicated married in item 6, complete items 18(a) and (b). 18. (a) Would any of questions 10 through 12 inclusive require a Yesanswer if asked of your spouse? (b) Will your spouse aid in the management of the applicant business? Yes No

Yes

No

If you answered Yes to either of the above, your spouse must complete a separate Personal Questionnaire.

Attach additional sheets as needed. Please include the item number referenced on additional sheets.

Page 4 of 4 CG-100-P (3/06) 19. Indicate your contribution to the applicant. Include cash, real estate, customer lists, promissory notes, inventories, and any other tangible or intangible assets. Contribution Cash Real estate Inventory Customer lists Tangible assets Intangible assets Other Other If you are guaranteeing a loan as a cosigner or by pledging collateral
(identifyeachsuchtransactionbelow)

Amount or value

Source of funds. If a current bank or brokerage account, give account number; for gifts or loans, identify source; if proceeds from the sale of assets, identify specific assets.

Amount or value

Identify loan and describe the collateral

Cosigner Cosigner

Collateral Collateral

20. For purposes of this application the term controllingperson 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 an officer or director with respect to a corporation) of an applicant for an agent's or wholesale dealer's license under Article 20 of the Tax Law, or if the applicant is a corporation, a shareholder, directly or indirectly, owning more than 10% of the number of share 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. I understand that the information I submit herein will be relied upon by the New York State Department of Taxation and Finance and a false statement or misrepresentation may constitute cause for the disapproval of the application or revocation of any license for which this application is submitted. I affirm that statements made herein are true and if any change occurs prior to the receipt of the license, I will notify the NYS Department of Taxation and Finance at the address shown on page 1 of this form by registered or certified mail within 48 hours. If a change occurs after receipt of the license, I understand that I must advise the Department prior to the occurrence of any change of ownership and/or location. The Department must be notified within 10 days of all other changes.

Signature

Title

Date

Privacy notification
The Commissioner of Taxation and Finance may collect and maintain personal information pursuant to the New York State Tax Law, including but not limited to, sections 171, 171-a, 287, 308, 429, 475, 505, 697, 1096, 1142, and 1415 of that Law; and may require disclosure of social security numbers pursuant to 42 USC 405(c)(2)(C)(i). This information will be used to determine and administer tax liabilities and, when authorized by law, for certain tax offset and exchange of tax information programs as well as for any other lawful purpose. Information concerning quarterly wages paid to employees is provided to certain state agencies for purposes of fraud prevention, support enforcement, evaluation of the effectiveness of certain employment and training programs and other purposes authorized by law. Failure to provide the required information may subject you to civil or criminal penalties, or both, under the Tax Law. This information is maintained by the Director of the Registration and Data Services Bureau, NYS Tax Department, Building 8, Room 338, W A Harriman Campus, Albany NY 12227; telephone 1 800 225-5829. From areas outside the United States and Canada, call (518) 485-6800.