PO BOX 269, TRENTON, NJ 08695-0269
Please answer all questions and provide a detailed explanation when requested If more room is needed, you may attach separate pages
as necessary.
1. Identification
Legal Name
Business or Trade Name
Federal Employer ID Number (FEIN) New Jersey State Corporation Number Fiscal Year End
Headquarters/Main Office
Address ______________________________________________________________________________________________
City, State, Zip ______________________________________________________________________________________________
Web Address ______________________________________________________________________________________________
Contact Person ______________________________________________________________________________________________
Email Address ______________________________________________________________________________________________
Telephone ______________________________________ FAX _____________________________________________
2. Type of Business Entity (check one)
State of Corporation ___________________________________________
Date of Corporation____________________________________________
Partnership: List all Partners, FEIN or Social Security Number, and addresses on a separate attachment.
Proprietorship: List Owner Name and SSN
Owner Name ____________________________________________________ SSN_________________________________________
Limited Liability: List type (e.g. LLC, LLP, Single Member) ______________________________________
a.) Indicate which form you file with the IRS (e.g. 1120, 1065) ______________________________________
b.) If you file Form 1065, list all members with FID or SSN and address on a separate attachment.
c.) If you are a Disregarded Entity, list the owner or owners with FEIN or SSN and addresses on a separate attachment.
Tax Exempt or Non-Profit: Please attach IRS documentation
3. List all certificates, registrations, licenses and authorizations issued by any New Jersey State Agency and date
issued. Complete even if certificates, etc. have expired or been withdrawn. In such cases indicate ending date. (If
none, write none.)
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4. Did your business, currently, or at any time, have any agents, independent representatives, subcontractors, third parties, etc., who
worked on your behalf in New Jersey?
YES. Please state the names and address of all agents, independent representatives, sub-contractors, third parties, etc. who
worked on your behalf in New Jersey, on a separate attachment.
5. Provide the address where the books and records of the business are located.
Street ______________________________________________________________________________________________________________
City, State and Zip ____________________________________________________________________________________________________
Contact Person and Phone Number ______________________________________________________________________________________
If the books and records are located in New Jersey, please provide the date that the location was established. _______________________
6. Provide the address where the actual seat of management and control is located.
Street ______________________________________________________________________________________________________________
City, State, Zip ______________________________________________________________________________________________________
Contact Person and Phone Number ______________________________________________________________________________________
If located in New Jersey, please provide the date that the location was established. _____________________________________________
7. Is this entity related to any other company (parent, subsidiary, internet seller, etc.) with business activities in New
YES; Please provide the complete name and address of each related company, the manner in which it is related and the type of business
conducted in New Jersey. Also, if this entity has or had at any time, any activity at any related company’s New Jersey address, please de
scribe, in detail, any inter-company transactions. Please provide the information on a separate attachment.
8. Is this entity a partner in a partnership or LLC doing business in or deriving income from New Jersey?
YES; Please provide the name and address of each partnership or LLC and all partners on a separate attachment. Also
indicate the date that this entity became a partner, and when the partnership or LLC commenced business in or began
deriving income from New Jersey.
9. Status of Business
Dormant, Inactive
Dissolved (Attach Certificate of Dissolution)
Non Survivor of Merger (Please provide the following information on a separate attachment: date of merger, name, address and FEIN of
surviving entity.)
Other (Please provide details on separate attachment)
10. Total gross revenue for past years as reported to IRS:
Tax Year ______________ Gross Revenue ______________________ Tax Year ____________________ Gross Revenue _____________________________
Tax Year ______________ Gross Revenue ______________________ Tax Year ____________________ Gross Revenue _____________________________
11. Total gross revenue from New Jersey for past four years:
Tax Year ______________ NJ Revenue _________________________ Tax Year ____________________ NJ Revenue ________________________________
Tax Year ______________ NJ Revenue _________________________ Tax Year ____________________ NJ Revenue ________________________________
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Name: FEIN:
1. Nature of business activity conducted everywhere: ______________________________________________________________________
a. Federal Business Activity Code: _______________________________________________________________________________________
2. Nature of business activity conducted in New Jersey: ____________________________________________________________________
3. Did this company NOW or EVER conduct any of the following activities in New Jersey:
If “YES” insert first date (Month and Year) in “YES” box. if “NO” insert “X” in “NO” box.
Month/Year “X”
a. Do any business or conduct any type of activity in New Jersey? a
b. Derive any type of income from sources located in New Jersey (sales b
receipts, fees for services, franchise fees, royalties, licensing fees, management fees)?
Specify type:__________________________________________________________
c. Have employees, officers, agents and/or independent representatives working c
in New Jersey on behalf of the company?
d. Solicit sales in New Jersey? d
If yes, check any that apply:
For tangible personal property By in-state employees, agents, reps., etc.
For intangible property By mail, phone, publication, internet, etc.
For services Other. Explain on a separate attachment
e. Sell any type of goods, property or services to customers located in e
New Jersey? if yes, check all that apply:
Tangible personal property to resellers
Tangible personal property to customers
Services performed in New Jersey.
Services performed outside New Jersey.
f. Does the business have employees, representatives, related entities, agents f
or independent contractors who perform the following activities in New Jersey:
Make repairs or provide maintenance, service or replace faulty or damaged goods
Collect current or delinquent accounts.
Investigate credit worthiness.
Install, supervise or inspect installation.
Conduct training.
Give technical assistance.
Resolve customer complaints and credit disputes.
Approve or accept customer orders.
Repossess property or accept sale returns.
Secure deposits on sales.
Pick up or replace damaged or returned property.
Hire or train personnel.
Use agency stock checks.
Have a display at a New Jersey location in excess of 14 days.
Carry samples for sale or exchange.
Have goods on consignment.
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Name: FEIN:
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g. Lease tangible property to others for use in New Jersey? g
(If yes, attach a copy of the lease agreement)
h. License the use of any type of intangible right from which royalties, h
licensing fees, etc., are derived from the use of these rights in New Jersey.
(software licenses, trademarks, etc.)?
i. Perform any type of service in New Jersey (other than for solicitation of i
sales) such as constructing, erecting, installing, repairing, consulting, training,
conducting seminars or meetings, credit investigations by employees, agents,
subcontractors, and/or independent representatives?
j. Provide any technical assistance or expertise in New Jersey by employees j
agents, subcontractors, and/or independent representatives?
k. Perform any detail work by employees, agents, representatives and/or k
subcontractor, such as taking inventory, stocking shelves, maintaining displays,
arranging delivery, etc.?
l. Carry goods, merchandise, inventory, etc., into New Jersey for sale to l
customers in New Jersey?
m. Performs any of the following in New Jersey: Make deliveries, pick-up m
and/or replacement of goods?
With Common Carriers (submit name and address) With company owned vehicles
With Contract Carriers (submit name and address
n. Provide any type of maintenance program which is performed in New n
Jersey by either this entity of a hired independent contractor?
o. Have employees, independent contractors, and/or other representatives with o
in-home office in New Jersey for which they are reimbursed for expenses other
than telephone or travel?
p. Have the use of any office or any type of facility in New Jersey (whether p
owned or leased)?
q. Have the use of any property located in New Jersey (whether owned q
or leased)?
r. Have a telephone listing in New Jersey? If yes, provide phone number r
and address. ____________________________________________
s. Own or lease equipment or vehicles registered in New Jersey, which are s
provided to employees, agents, representatives, subcontractors, and/or
independent contractors. If “yes”, please provide full details on separate attachment.
t. Have any type of property located in New Jersey (whether owned, leased or t
rented, real estate, consignments, inventory, computer servers, merchandise,
display racks etc.)?
u. Collect and/or remit New Jersey Gross Income Tax withholding from u
employees at any time?
v. Collect and/or remit New Jersey Sales Tax at any time? v
w. Does the business enter into agreements with representatives in w
New Jersey who refers customers to the business by a link on an
internet website or otherwise?
x. Does the business receive income such as interest, fees or annual charges on x
any loans, credit cards, mortgages, etc. from New Jersey residents?
y. Does the business make personal loans, car loans, or mortgages to y
New Jersey residents?
Name: FEIN:
z. Does the business purchase or sell mortgage loans secured by real estate z
in New Jersey?
aa. Did the business at anytime participate as an exhibitor at a trade show aa
or take orders at a trade show in New Jersey?
bb. Is the business related to a company utilizing intangible assets in bb
New Jersey?
cc. Does the business own, lease or maintain in-state facilities such as cc
a warehouse or answering service?
dd. Does the business perform construction contracts in New Jersey? dd
ee. Does the business perform as a subcontractor in New Jersey? ee
ff. Has the business ever executed contracts in New Jersey? ff
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AFFIRMATION:I declare, under penalty of perjury, that
the information provided in the questionnaire and any
attachments is, to the best of my knowledge, true,
correct and complete. if prepared by a person other
than an officer, partner or owner of the business, this
declaration is based on all information on which you
have knowledge.
Date _________________________________
Print Name _________________________________
Signature _________________________________
Title _________________________________
More information is available on the Division’s website at: www.state.nj.us/treasury/taxation/.
New Jersey Division of Taxation
Nexus Audit Group
PO Box 269
Trenton, NJ 08695-0269
PHONE: 609-984-5749
Name: FEIN: