ABC USE
KANSAS DEPARTMENT OF REVENUE
Division of Taxation
Appr. Date
Topeka, KS 66625-0001
Initials
(785) 296-4460
BUSINESS TAX APPLICATION
PLEASE TYPE OR PRINT
PART 1 - TAX TYPE - Check the box for each tax type that you are applying for
Retailers' Sales Tax
Liquor Excise Tax
Transient Guest Tax
Retailers' Compensating Use Tax
Liquor Enforcement Tax
Tire Excise Tax
Consumers' Use Tax
Cigarette Vending Machine License & Permits
Vehicle Rental Excise Tax
Employers' Withholding Tax
Retail Cigarette License
Dry Cleaning Surcharge
PART 2 - BUSINESS INFORMATION - Answer all questions completely
1 .
Business Name
2 .
Business Mailing Address
(Street, Route or PO Box including Apartment Number, Suite Number or Lot Number)
(City)
(State)
(Zip)
3 .
Business Phone Number (
)
FAX # (
)
4 .
Federal Employer's Identification Number (FEIN)
—
5 .
Accounting Method (Check One):
Cash basis
Accrual basis
6 .
Type of Ownership (Check One):
Individual
Partnership
Limited Liability Company
Corporation — Date and state of incorporation:
State of commercial domicile:
Other
7 .
List the name and FEIN of your parent company if applicable:
Name
FEIN
—
8 .
Describe your business activity (for example grocery store, plumbing contractor, leasing vehicles, employer)
9 .
Have you or any member of your firm previously held a Kansas number?.................................................
Yes
No
If yes, account number or name under which issued
10.
List all registration numbers currently used for reporting Kansas taxes:
a)
Sales/Use Tax
b)
Liquor Excise
c)
Withholding
d)
Cigarette
e)
Other
PART 3 - OWNERSHIP INFORMATION - List all owners, partners, corporate officers or directors
1 .
Name
SSN
-
-
Home Address
City
State
ZIP
Home Telephone (
)
Title
2 .
Name
SSN
-
-
Home Address
City
State
ZIP
Home Telephone (
)
Title
3 .
Name
SSN
-
-
Home Address
City
State
ZIP
Home Telephone (
)
Title
4 .
Name
SSN
-
-
Home Address
City
State
ZIP
Home Telephone (
)
Title
CONTINUE WITH PARTS 4, 5, 6, 7 AND 8 ON THE REVERSE SIDE OF THIS FORM
OFFICE USE ONLY
Sales
With
Vend Machine
Comp
Liq Exc
Ret Cig
Cons
Liq Enf
Tran Gst
BT/rg-16 (Rev. 7/97)
1
2
