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CAT RTFS

Prescribed 12/05

Commercial Activity Tax – Request to File Separately*

Primary taxpayer’s name ____________________________________________________________________________

Address _________________________________________________________________________________________

City _________________________________________________

State _______

ZIP code___________________

FEIN or social security no. _____________________________ CAT account no. _______________________________

Member requesting to file separately _______________________________________________________________

Address ________________________________________________________________________________________

City ____________________________________________________ State _______ ZIP code__________________

FEIN or social security no. _____________________________ CAT account no. _____________________________

Reason for request to file separately (must list specific reasons/issues)

Check here if continued on attached page

Note: This request may be made only by combined taxpayer groups. If this request is granted, the member requesting

to file separately may not elect to consolidate with other members of the same or a different taxpayer group. The tax

commissioner may revoke special filing approval at any time.

Effective date of separate filing (if different from the succeeding tax period) ___________________________________

Note: Special approval by the tax commissioner is required for the separate filing to begin with the current tax period.

Please attach a letter documenting reasons for this request.

Primary taxpayer and member agree to the following: The separately filing member may not claim any of the group’s

$250,000 quarterly exclusion. The member will file as a separate taxpayer and will be subject to the applicable tax rate on

all of the member’s taxable gross receipts without any quarterly exclusion. The separately filing member is financially

sound and currently able to pay the commercial activity tax. All members, including the separately filing member, remain

jointly and severally liable for the combined group’s tax liability.

I hereby declare the above to be true and correct to the best of my knowledge and belief.

_________________________________________________________________________________________________

Primary taxpayer representative

Signature

Date

_________________________________________________________________________________________________

Representative of member requesting to file separate

Signature

Date

Please send this request to: Ohio Department of Taxation, CAT Division-CAT RTFS, P.O. Box 530, Columbus OH

43216-0530 or fax to (614) 644-9641.

*This form is created pursuant to Adm. Rule 5303-29-08.

Commercial Activity Tax Form - Request To File Separately - Ohio Department Of Taxation