Free 46609.FH11 - Indiana

APPLICATION FOR ACCOUNTANCY FIRM PERMIT
State Form 46609 (R4 / 5-07) Approved by State Board of Accounts, 2007

Reset Form

INDIANA BOARD OF ACCOUNTANCY PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-3040 E-mail: [email protected]

* Your Federal Identification Number is being requested by this state agency in accordance with Indiana Code § 4-1-8-1. Disclosure is voluntary
and you will not be penalized for refusal. Federal Identification Numbers may be made available to the Indiana Department of Revenue.
FOR OFFICE USE ONLY APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER LICENSE NUMBER ISSUED DATE LICENSE ISSUED (month, day, year) LICENSE OBTAINED BY

DO NOT WRITE ABOVE THIS LINE
Pursuant to IC 25-2.1-5-7, an applicant shall notify the Indiana Board of Accountancy in writing, not more than thirty (30) days after a change: (a) in the identities of partners, members, officers, or shareholders who work regularly in Indiana; (b) in the number or location of offices in Indiana; (c) in the identity of the individuals in charge of the offices; and (d) of the issuance, denial, revocation, or suspension of a permit by another state.
Federal ID number * Date (month, day, year )

The firm known as _______________________________________________________________________________________ is engaged in the practice of public accountancy in this state and hereby makes application for a Permit to Practice Accountancy pursuant to IC 25-2.1-5. This firm is a (check one ): Sole Proprietorship Corporation Partnership Professional Corporation Limited Liability Partnership Limited Liability Company

1. The name and address of the principal office of the firm within the state of Indiana is:
Name of principal office Address (number and street, city, state, and ZIP code) Telephone number ( ) E-mail address

2. Other offices located within the state of Indiana (attach additional listing if necessary): Office address
(number and street, city, and ZIP code)

Name of office manager

Indiana PA-AP certificate number

Indiana CPA certificate number

CPA of state other than Indiana

(1)

3. The name and Indiana certificate number of the sole proprietor (if applicable), each partner, member, officer, or shareholder who regularly works in Indiana. the total percentage of equity ownership and the voting rights of the licensees in the firm. Attach an additional 8 1/2 x 11 sheet if necessary. Name of Sole Proprietor, Partner, Member, Officer, or Shareholder Indiana Certificate Number Percentage of Equity Ownership and Voting Rights

4. The name of each nonlicensed CPA/PA/AP partner, member, officer, or shareholder, job title, percent of ownership, and percent of time devoted to client service. Attach an additional 8 1/2 x 11 sheet if necessary. Name of Partner, Member, Officer, or Shareholder Job Title Percent of Ownership Percent Devoted to Client Service

5. The name and Indiana certificate number of each employee holding a certificate who regularly works in Indiana. Attach an additional 8 1/2 x 11 sheet if necessary. Name of Employee Indiana Certificate Number

(2)

5. The name and Indiana certificate number of each employee holding a certificate who regularly works in Indiana. (Continued from previous page.) Name of Employee Indiana Certificate Number

6. The name and out-of-state certificate number of each partner, member, officer, or shareholder who does NOT regularly work in Indiana. Attach an additional 8 1/2 x 11 sheet if necessary. Name of Partner, Member, Officer, or Shareholder State of Licensure Certificate Number (if applicable)

7. List each state in which the applicant / firm has applied for or holds a permit to practice accountancy as a firm. List any past denial, revocation, or suspension of a permit by another state. Attach an additional 8 1/2 x 11 sheet if necessary. Name of Applicant / Firm State of Licensure Certificate Number (if applicable) Status

Signature of Indiana Certificate Holder

Date (month, day, year)

(3)