1

3 Reason for applying: new business changeoflegalorganization purchasedexistingbusiness(see instructions, page 2,“Successor Liability”): prior Minnesota tax ID number: Former owner’s name: forinformationalpurposes,suchasavendororbusinessreceivinggrantsoranytypeofpaymentfromastateagency (complete pages 1 and 2 only)

4 Full legal name of the business (sole proprietors: fill in last name, first name, middle initial)

5 Business trade name (doing business as),ifyouhaveone

6 Completeaddressofbusinesslocation (Do not use P.O. box) County

City State Zip code

7 Mailing address (if different from above) City State Zip code

8 Daytimephone Otherphonenumber Faxnumber

9 Email address Website address

10 Type of legal organization:

11a Types of taxes you expect or are required to pay and/or collect: Business taxes — Check all that apply and complete the corresponding section on the page indicated: Sales and use tax (see pages 3, 4, and 5) Insurance taxes (see page 6) Other special taxes (see page 7) Withholding tax (see page 6) Petroleum taxes (see page 7) MinnesotaCare taxes (see page 10) Windenergyproductiontax(see page 8) Solarenergyproductiontax(see page 8)

Income,franchiseorunrelatedbusinessincometaxes—Check one box only and complete the registration section on page 9: Scorporation Estateortrust(fiduciary) Unrelated business income tax Partnership Ccorporation

You must provide additional information for each tax type you checked on line 11a.

Continue with line 11b on page 2.

2 Current or prior Minnesota taxIDnumber(s),ifany (seven digits) . . . . . . . . . . . . . . . . .

Should this number be canceled? No Yes,canceleffective

Application for Business Registration

ABR

1 Federal tax ID number (nine digits). See instructions, page 3

(mm/dd/yyyy)

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You can register online at www.revenue.state.mn.us.Ifyouchoosetofilethispaperapplication,fullycompletepages1and2andanypagesneededtoregisterforaspecifictaxtype.Incompleteapplicationsmaybedelayed.Readtheinstruc-tionsbeforecompleting.

(Rev.1/18)

5aIsthisaqualifiedbusinessparticipating in a Job Opportunity Building Zone (jobz)? No Yes. Enter JOBZ ID number: 5b Is this business located on a MinnesotaIndianreservation? No Yes. Specify:

Sole proprietor

Partnership:

Generalpartnership,or

Limitedliabilitypartnership(LLP),or

Limited partnership (LP)

Scorporation

Limited liability company (LLC): One member only (see inst., pg. 4),or

Two or more members

Cooperative Estateortrust(fiduciary) Ccorporation

Nonprofitcorporation Nonprofitorganization Qualifiedjointventure Government

Other (please specify):

2

n call 651-282-5225 or 1-800-657-3605

n fax your completed pages to 651-556-5155 (Do not fax blank pages.)

n mail your completed pages to: MinnesotaDepartmentofRevenue MailStation4410 St.Paul,MN55146-4410

Do not mail if you register online, by phone or by fax.

To avoid receiving unnecessary tax bills and/or delinquency notices, you must let us know if:

n informationchangesatanytimeafteryoufilethisapplication,

n yougooutofbusiness,

n youquitmakingtaxablesales,leasesorservices,or

n younolongerhaveemployees.

Toupdateyourbusinessinformation,goto www.revenue.state.mn.usorcallusat651-282-5225or 1-800-657-3605.

11b If you want toreceiveaneducationalphonecallfromthedepartment,indicatebelowthetype(s)oftaxyouareinterestedin: Sales and use tax Insurance taxes Partnership Ccorporation Withholding tax Petroleum taxes MinnesotaCare taxes Productiontaxes Scorporation Estateortrust(fiduciary) Unrelated business income tax Other special taxes

Also,whenisthebesttimeofdaywecanreachyou?

Business activities

12 Enter the six-digit NAICS code(s) that best describe yourbusinessactivities(enter at least one) . . . . . . . . . . . . . IfyoudonotknowyourNAICScode,gotohttp://www.census.gov/eos/www/naics/index.html.Enterakeywordtosearchthe

most recent NAICS list.

Describeyourbusinessactivitiesbelow,includingthetypeofindustry—retailorwholesaletrade,manufacturing,transporta-tion,services,etc.Alsodescribeyourmainbusinessactivityandotheractivitiesyouwillbedoing.

13 Accountingperiodusedbybusiness: Calendar year (sole proprietors are automatically signed up for calendar year)

Fiscalyear.Fillinfiscalyear-endmonth:

14 List INDIVIDUALSwhoareowners,officersortrustees/personalrepresentatives(requiredifapplicable). Note:Partnerships,LLPsandmulti-memberLLCsfilingasCorporations,ScorporationsorPartnershipsmusthaveatleast2owners/ officerslisted.Attachaseparatesheetifneeded. Name(lastname,firstname,middleinitial) SocialSecuritynumber(required) Date of birth

Homeaddress(street,city,state,zipcode) Businessphone Homephone

Name(lastname,firstname,middleinitial) SocialSecuritynumber(required) Date of birth

Homeaddress(street,city,state,zipcode) Businessphone Homephone

Name(lastname,firstname,middleinitial) SocialSecuritynumber(required) Date of birth

Homeaddress(street,city,state,zipcode) Businessphone Homephone

15 List BUSINESSESthatareowners,trusteesorpersonalrepresentatives(requiredifapplicable).Note:Partnerships,LLPsandmulti- memberLLCsfilingasCorporations,ScorporationsorPartnershipsmusthaveatleast2owners/officerslisted. Attachaseparatesheetifneeded. Name of business owner Federal tax ID number (required) MinnesotataxIDnumber,ifany

Address(street,city,state,zipcode) Businessphone Otherphone

Name of business owner Federal tax ID number (required) MinnesotataxIDnumber,ifany

Address(street,city,state,zipcode) Businessphone Otherphone

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If you choose not to register online, complete pages 1 and 2 and any required registration pages (see line 11a). To register:

3

1 Date of first Minnesota taxable sale, lease, service or use tax obligation:

2 Accountingmethod (check one box; see instructions, page 5 for definitions):

Cash basis Accrual basis Other:

3 Ifyourbusinessisseasonal,checkthemonthsyourbusinessisactiveforsalesand/orusetax:

January March May July September November

February April June August October December

4 Mailingaddressforsalesandusetaxinformation City State Zipcode

Contactpersonwithinorganizationforsalesandusetax Title Daytimephone

Email address Fax number

5 Filingfrequencyisbasedonyouraverageestimatedsales and use tax for one month. If you expect your sales and use tax to be (check one box):

$500 or more per month,youwillberequiredtofilemonthly.

less than $500 per month,youwillberequiredtofilequarterly.

$100 or less per month,youwillberequiredtofileannually.

for only one event or during one month and you do not plan to make future taxable sales in Minnesota,youwillberequiredtofileone-timeonly.

6 Checktheboxesbelowtoindicatethetypesofgoodsandservicesyouwillbeproviding,ifany(seeinstructions,page:

Car rentals Mobile homes and park trailers Wastecollectionservices

Interstate motor carriers On-sale/off-saleliquor Prepaid Wireless None apply to this business (E911/TAMFees)

7 Will you be making taxable sales from more than one permanent location(see instructions, page 5)? . . . . . . . . . . . . . . . No Yes

If yes, provide the following information for each location. Attach a separate sheet, if needed. a. Location’sbusinessname Dateoffirsttaxablesale,lease,service orusetaxobligationforanylocaltax: Locationaddress City State Zipcode

Enter the six-digit NAICS code(s) that best describe thislocation’sbusinessactivities(enteratleastone): Describethislocation’sbusinessactivities,includingthetypesofgoodsandservicesprovided:

b. Location’sbusinessname Dateoffirsttaxablesale,lease,service orusetaxobligationforanylocaltax: Locationaddress City State Zipcode

Enter the six-digit NAICS code(s) that best describe thislocation’sbusinessactivities(enteratleastone): Describethislocation’sbusinessactivities,includingthetypesofgoodsandservicesprovided:

Sales and use tax registration continues on page 4.

Sales and Use Tax

IfyouintendtoselltaxableitemsorprovidetaxableservicesinMinnesota,youmustregistertocollect,reportandremitMinnesotastateandanyapplicablelocaltaxes.Ifyoumakebusinesspurchasessubjecttousetax,youmustregisterforusetaxfiling.

Salesandusetaxreturnsarefiledelectronically,eitherovertheInternetorbytelephone.

month day year

Stat

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Taxable State tax sales of rate Average

$7,273x6.875% ≅$500tax $1,455x6.875% ≅ $100tax

4

Local taxes TheDepartmentofRevenuealsoadministersandcollectslocaltaxesonbehalfofspecificlocalgovernments.Ifyoumakeretailsalesordobusinessinalocationthatimposesalocaltax,youmustregisterforthelocaltax.

Review the list of local taxes below and check all the boxes that apply. ThelistisaccuratethroughMarch1,2016.SeeSalesTaxFactSheets164,164M,and164S,availableonourwebsite,foranup-to-datelistoflocaltaxesthatmayhavebeenenactedsincethatdate.

8 Checkalltheboxesthatapply,andfillintheeffectivedateofyourfirsttaxablesale,lease,serviceorusetaxobligation(see instruc-tions, page 6):

Sales and Use Tax (continued)Lo

cal t

axes

Albert Lea sales and use . . . . . . . . . 0.50% Anoka County

transit sales and use (effective October 1, 2017) 0.25% Vehicle excise tax . . . . . . . . . . . $20.00

Austinsalesanduse . . . . . . . . . . . . 0.50% Baxter sales and use . . . . . . . . . . . . 0.50% Becker County transit sales and

use (effective July 1, 2014) . . . . . . . 0.50% Beltrami County transit sales and

use (effective April 1, 2014) . . . . . . 0.50% Transitexcisetax(pervehicle) (effective April 1, 2014) . . . . . $20.00

Bemidjisalesanduse . . . . . . . . . . . 0.50% Blue Earth County transit sales and use

(effective April 1, 2016) . . . . . . . . . 0.50% Brainerd sales and use . . . . . . . . . . 0.50% Brown County transit sales and use

(effective April 1, 2016) . . . . . . . . . 0.50% Carlton County transit sales

and use (effective April 1, 2015). . . .0.50% Carlton County transit excise tax

(per vehicle) (effective April 1, 2015) . . . . . . . . $20.00

CarverCounty (effective October 1, 2017) Transit sales and use . . . . . . . . 0.50% Vehicle excise tax . . . . . . . . . . . $20.00

Cass County transit sales and use (effective April 1, 2016) . . . . . . . . . 0.50%

Chisago County transit sales and use (effective April 1, 2016) . . . . . . . . . 0.50%

Clay County sales and use (effective October 1, 2017) . . . . . . . 0.50%

Clearwater sales and use . . . . . . . . 0.50% Cloquet sales and use

(effective April 1, 2013) . . . . . . . . . 0.50% Cook County sales and use . . . . . . . 1.00% Crow Wing County transit sales and use

(effective April 1, 2016) . . . . . . . . . 0.50% Dakota County (effective October 1, 2017)

Transit sales and use . . . . . . . . 0.25% Vehicle excise tax . . . . . . . . . . . $20.00

DetroitLakesFoodandbeverage . 1.00% Douglas County transit sales and

use (effective October 1, 2014). . . . 0.50% Duluth sales and use . . . . . . . . . . . . 1.00% East Grand Forks sales and

use (effective January 1, 2018) . . . 1.00%

Location and tax Rate Effective date Location and tax Rate Effective date (mm/dd/yyyy) (mm/dd/yyyy)

Fairmont local sales and use (effective October 1, 2017). . . . 0.50%

Fergus Falls sales and use (effective January 1, 2018) . . . . . . . 0.50%

Fillmore County transit sales and use (effective January 1, 2015) . . . . . . . 0.50%

Freeborn County transit sales and use . . . . . . . . . . . . . . . . . . . . . . . . . . .0.50% (effective January 1, 2016)

Garrison,Kathio,WestMilleLacs Lake Sanitary District sales and use (effective January 1, 2018) . . . . . . . 1.00%GiantsRidgeRecreationArea Admissionsandrecreation . . . 2.00% Foodandbeverage . . . . . . . . . 1.00% Lodging . . . . . . . . . . . . . . . . . . . 2.00%

Hennepin County Sales and use . . . . . . . . . . . . . . 0.15% Transit sales and use (effective October 1, 2017) . . . 0.50% Vehicle excise tax . . . . . . . . . . . $20.00

Hermantown sales and use (effective April 1, 2014) . . . . . . . . . . 1.00%

Hubbard County transit sales & use (effective January 1, 2015) . . . . . . . 0.50%

Hutchinson sales and use (effective January 1, 2012) . . . . . . . 0.50%

Lanesboro sales and use (effective January 1, 2012) . . . . . . . 0.50%

Lyon County transit sales and use . . . . . . . . . . . . . . . . . . . . . . . . . . .0.50% (effective October 1, 2015)

Mankato sales and use . . . . . . . . . . 0.50% Foodandbeverage . . . . . . . . . 0.50% Entertainment . . . . . . . . . . . . . 0.50%

Marshall sales and use (effective April 1, 2013) . . . . . . . . . 0.50% Foodandbeverage (effective July 1, 2013) . . . . . . . 1.50%

Medford sales and use (effective April 1, 2013) . . . . . . . . . 0.50%

Minneapolis sales and use . . . . . . . 0.50% Downtown liquor . . . . . . . . . . . 3.00% Lodging (effective October 1, 2017) . . 2.125% Downtown restaurant . . . . . . . 3.00% Entertainment . . . . . . . . . . . . . 3.00%

Sales and use tax registration continues on page 5.

5

Sales and Use Tax (continued)Lo

cal T

axes

Morrison County transit sales and use (effective January 1, 2018) . . . . 0.50%

Moose Lake local sales and use (effective October 1, 2017). . . . 0.50%

Mower County transit sales and use (effective January 1, 2018) . . . . 0.50%

New London local sales and use (effective October 1, 2017). . . . 0.50%

New Ulm sales and use . . . . . . . . . .0.50% Nicollet County transit sales and

use (effective January 1, 2018) . . . . 0.50% North Mankato sales and use . . . . 0.50% Olmsted County transit sales

and use (effective January 1, 2014) . . . . . . . 0.25%

OtterTailCountytransitsalesand use (effective January 1, 2016) . . . . 0.50% Excise tax (per vehicle) . . . . . . . $20.00 (effective January 1, 2016)

Polk County transit sales and use (effective January 1, 2018) . . . . 0.25%

Proctor Foodandbeverage (effective April 1, 2015) . . . . . . .1.00% Sales and use (effective October 1, 2017) . . . .1.00%

Ramsey County (effective October 1, 2017) Transit sales and use . . . . . . . . 0.50% Vehicle excise tax . . . . . . . . . . . $20.00

Rice County transit sales and use (effective January 1, 2014) . . . . . . . 0.50%

Rochester sales and use tax . . . . . . 0.75% (effect January 1, 2016) Lodging (effective January 1, 2014). . . . 7.00%

ScottCountytransitsalesand use . . . . . . . . . . . . . . . . . . . . . . . . . . .0.50% (effective date October 1, 2015) Excise tax (per vehicle) (effective October 1, 2015) . . . $20.00

Spicer sales and use (effective October 1, 2017). . . . . . . 0.50%

Location and tax Rate Effective date Location and tax Rate Effective date (mm/dd/yyyy) (mm/dd/yyyy)

Stearns County transit sales and use (effective January 1, 2018) . . . . 0.25%

Steele County transit sales and use (effective April 1, 2015) . . . . . . . . . 0.50%

St. Cloud Area sales and use (includes the cities of Sartell, Sauk Rapids, St. Augusta, St. Cloud, St. Joseph and Waite Park) . . . . . . . . 0.50% St. Cloud food . . . . . . . . . . . . . 1.00% St. Cloud liquor . . . . . . . . . . . . 1.00%

St. Louis County transit sales and use (effective April 1, 2015). . . 0.50% Transit excise tax (per vehicle) (effective April 1, 2015) . . . . . $20.00

St. Paul sales and use . . . . . . . . . . . 0.50% Lodging (50 or more rooms) . . 6.00% Lodging (fewer than 50 rooms) . . 3.00%

Todd County transit sales and use (effective January 1, 2015) . . . . . . . 0.50%

Transitimprovementsalesand use tax (Anoka, Dakota, Hennepin, Ramsey and Washington counties) . . . 0.25% Transitimprovementvehicle excise tax (per vehicle) . . . . . $20.00

Two Harbors sales and use . . . . . . . 0.50% Wabasha County transit sales and

use (effective April 1, 2016) . . . . . . 0.50% Wadena County transit and use tax

(effective April 1, 2014) . . . . . . . . . . 0.50% Walker sales and use

(effective January 1, 2018) . . . . . . . 1.50% Washington County (effective October 1, 2017)

Transit sales and use . . . . . . . . 0.25% Vehicle excise tax . . . . . . . . . . . $20.00

Worthington sales and use tax . . . .0.50% Wright County transit sales

and use (effective October 1, 2017) 0.50% Other local taxing area(s)

Specify: . . . . .

6

Withholding Tax

YoumustregistertofileMinnesotawithholdingtax,ifyou:• Haveemployeesandanticipatewithholdingtaxfromtheirwagesinthenext30days;• AgreetowithholdMinnesotataxeswhenyouarenotrequiredtowithhold;• PaynonresidentemployeestodoworkforyouinMinnesota(see“Exceptions”intheMinnesotaIncomeTaxWithholdingInstructionBooklet)• MakeminingandexplorationroyaltypaymentsonwhichyouarerequiredtowithholdMinnesotataxes;or• AreacorporationwithcorporateofficersperformingservicesinMinnesotawhowillhavewithholdingfromtheirwages.

Withholdingtaxreturnsmustbefiledelectronically,eitherovertheInternetorbytelephone.

1 IndicatetheyearandquarteryouexpectthefirstMinnesotawagestobepaid:

Year: Quarter: 1st(January—March) 3rd(July—September)

2nd (April—June) 4th(October—December)

2 Are you applying only because you employ Minnesota residents and you do not conduct business in Minnesota? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes

3 Mailingaddressforwithholdingtaxinformation City State Zipcode

Contactpersonwithinorganizationforwithholdingtax Title Daytimephone

Email address Fax number

With

hold

ing

tax

Insurance Taxes

IfyouareaninsurancecompanyorinsurancesurpluslinesbrokerlicensedbytheMinnesotaDepartmentofCommerce,ahealthmaintenanceorganization(HMO),oranonprofithealthplancorporation,youmustberegisteredtofileandpayinsurancetaxes.Seeinstructions,pages7and8,for details.

3 Mailingaddressfortaxreturnsandinformation City State Zipcode

Contactpersonwithinorganization Title Daytimephone

Email address Fax number

Insu

ranc

e ta

xes

1 NAIC number (National Association of State/country Insurance Commissioners) . . . . . . . . . . . . . . ofincorporation . . . . . . . . . . . . .

2 Type(s) of insurance tax or surcharge you are required to pay (check all that apply and indicate the effective date for each box checked):

Insurance taxes and surcharges Effective date (mm/dd/yyyy)

Insurance premium tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Autotheftpreventionsurcharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Fire safety surcharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Firefighter’sreliefsurcharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

HMO insurance premium tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Surplus lines tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

sole proprietorship

7

1 Type(s) of special tax or fee you are required to pay (check all that apply and include effective date for each box checked):

Special taxes and fees Effective date (mm/dd/yyyy)

Cigarettetax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tobacco products tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Alcohol common carrier tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alcohol importer report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Distilledspiritstax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Maltbeveragetax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wine tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Drycleanerregistrationfee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Drycleaningsolventsfee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

E-wasteregistrationfee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Lawful gambling licensed distributors report (enter license number: ) . . . . . . . . . . . . . . . . . . . . . . . Lawful gambling licensed manufacturers report (enter license number: ) . . . . . . . . . . . . . . . . . . . . . . . Lawful gambling taxes (enter license number: ) . . . . Wireless . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other,pleasedescribe: . . .

2 Mailingaddressfortaxreturnsandinformation City State Zipcode

Contactpersonwithinorganization Title Daytimephone

Email address Fax number

Other Special Taxes

Dependingonyourbusinessortypesofgoodsandservicesyouprovide,youmayberequiredtoregistertofileandpayothertypesofspecialtaxesorfees.Seeinstructions,page9,fordetails.

Oth

er sp

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es

1 Effectivedateofthepetroleumtax:

2 Mailingaddressfortaxreturnsandinformation City State Zipcode

Contactpersonwithinorganization Title Daytimephone

Email address Fax number

Petroleum Taxes

Youmustregistertofileandpaypetroleumtaxesandfeesifyouarealicenseddistributorofgasoline,asellerofspecialfuels,oranownerofve-hiclesusingcompressednaturalgas,propaneorotheralternativefuel.Seeinstructions,page8,fordetails.

month day year

Petr

oleu

m ta

xes

8

1 Type of system:

SolarEnergyGeneratingSystem WindEnergyConversionSystem

2 Combinednameplatecapacity(inmegawatts):

3 Date system began producing energy:

4 Mailingaddressfortaxreturnsandinformation City State Zip code

5 Contactpersonwithinorganization

Name Title

DaytimePhone EmailAddress

month day year

YoumustregistertofiletheSolarEnergyProductionTaxifyouproduceelectricitybymeansofasolarenergygeneratingsystemwithanameplatecapacityexceedingonemegawattalternatingcurrent.

YoumustregistertofiletheWindEnergyProductionTaxifyouproduceelectricitybymeansofawindenergyconversionsysteminstalledafterJanuary1,1991,withanameplatecapacityexceeding0.25megawattsorwithanameplatecapacityexceedingtwomegawattsifownedbyapoliticalsubdivision.

Solar and Wind Energy Production TaxesSo

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Tax

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9

If your business is (check one box only):

an S corporation or limited liability company considered to be an S corporation for federal tax purposesandyouhaveproperty,payrollorsalesinMinnesota,youarerequiredtofileannualScorporationtaxreturns,FormM8.YouareanScorporationifyouelectedtobetaxedunderSubchapterSofInternalRevenueCode(IRC)section1362,and the IRS approved your election.

a. Stateofincorporation: Dateofincorporation:

Start date of the tax year you became liable for tax in Minnesota:

a partnership, limited liability partnership, or limited liability company considered to be a partnership for federal tax purposes,andyouhaveproperty,payrollorsalesinMinnesota,youarerequiredtofileannualpartnershipreturns,FormM3.

Ifyoucheckedthisbox,fillinthedatethepartnershipwasformed:

Start date of the tax year you became liable for tax in Minnesota:

an estate or trust (fiduciary) requiredtofileafederalincometaxreturnforestatesandtrustsandyouhave$600ormoreofgrossincomeassignabletoMinnesotaoryouhaveanonresidentalienasabeneficiary,youarerequiredtofileannualincometaxreturnsforestatesandtrusts,FormM2.

a. Date of death or date trust established:

b. Nameofestateortrust Forthebenefitof(FBO),ifapplicable

Trusteeorpersonalrepresentative FederalID/SocialSecuritynumber Daytimephone

Address City State Zip code

a corporation, cooperative, or limited liability companytaxedasacorporationbytheIRSandhaveincome,payroll,certainsalesactivitiesorown/leasepropertyinMinnesota,youarerequiredtofileannualcorporatefranchisetaxreturns,FormM4.

a. Stateofincorporation: Dateofincorporation:

Start date of the tax year you became liable for tax in Minnesota:

b. Relationshipwithanotherexistingcorporation: Subsidiary Division

Parentcorporation FederalIDnumber MinnesotaIDnumber

Address City State Zip code

atax-exemptorganization,cooperative,homeownerassociationorpoliticalorganizationdoingbusinessinMinnesotawithunrelated business income (UBI),youarerequiredtofileanannualUBItaxreturn,FormM4NP.Checkallboxesthatapply:

nonprofit organization or corporationwithUBIorliableforproxytaxonlobbyingandpoliticalexpendituresfilingfederalForm990-T, farmers’ cooperative,asdefinedinIRCsection521,filingfederalForm1120-C, homeowner associationfilingfederalForm1120-H,or political organizationfilingfederalForm1120-POL.

a. Tax-exempt status (check one): 501(c)( ); 501( ); 528;or Other:

b. Stateofincorporation: Dateofincorporation:

c. Relationshipwithanotherexistingcorporation: Subsidiary Division Parentcorporation FederalIDnumber MinnesotaIDnumber

Address City State Zip code

Income, Franchise or Unrelated Business Income TaxDepending on the type of your legal organization, you may be required to register to file an annual Minnesota tax return.Also,youwillneedaMinnesotataxIDnumberifyouexpectorwillberequiredtopayestimatedtax.Seeinstructions,page9,fordetails.

month day year

month day year

month day year

Inco

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month day year

month day year

Mailingaddressfortaxreturnsandinformation City State Zipcode

Contactpersonwithinorganization Title Daytimephone

Email address Fax number

1.

2.

month day year

month day year

month day year

10

Surgical center

Wholesaler of legend drugs and/or out-of-state pharmacy or mail order business selling legend drugs into Minnesota

Legend drug use tax

4 Mailing address for MinnesotaCare tax forms City State Zip code

ContactpersonwithinorganizationforMinnesotaCaretax Title Daytimephone

Email address Fax number

MinnesotaCare Taxes YoumustregistertofileandpayMinnesotaCaretaxesifyouare:• ahospitalorsurgicalcenter,• ahealth-careproviderwhoisregulatedorrequiredtoberegulatedbythestateofMinnesotatoprovidehealth-careservices,suchasmedical,

surgical,optical,visual,dental,hearing,nursing,drugs,laboratory,diagnosticortherapeutic,directlytoapatientorconsumer,• anemployerofalicensedorregisteredhealth-careprovider,includingprofessionalassociationsandstaffmodelhealth-plancompanies,• eligibletoreceivereimbursementfromtheMedicalAssistance(MA)programforthehealth-careservicesyouprovide,• asellerofhearingaidsandrelatedequipment,asellerofprescriptioneyewearoranambulanceservicerequiredtobelicensed,• abusinesslicensedtoselllegenddrugsatwholesaleinMinnesota,or• apharmacyorpersonwhopurchaseslegenddrugsfromawholesaler/manufacturer/pharmacynotsubjecttotheMinnesotaCaretax.

Seeinstructions,page11,fordetails.

MinnesotaCaretaxreturnsarefiledelectronically,eitherovertheInternetorbytelephone.

3 Type of taxpayer (check all that apply):

Hospital

Providerofhealth-careservices.Also,checktheboxesbelowthatbestdescribeyourbusiness:

2 Minnesotahospital,surgical centerorhealth-careprovider professional license number (if applicable):

Type of license:

License start date:

1 Dateoffirstreceiptsfromservicesorsales:

acupuncturepractitioner audiologist chemical dependency counselor chiropractor dental assistant dental hygienist dentist dietician emergency medical technician hearing aid dispenser licensedambulanceservice

(nonvolunteer) licensed graduate social worker

licensed independent clinical social worker

licensed independent social worker licensed or licensed associate

marriage and family therapist licensed midwife naturopathic doctor nurse,registerednurse,licensed

practicalnurse,nursingassistant nutritionist occupationaltherapist optician/opticalsupplier optometrist

osteopath paramedic physical therapist physician physician assistant podiatrist psychologist public health nurse respiratorycarepractitioner speech language pathologist staffmodelhealthplan other (specify):

(month, day and year)

month day year

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