Rev. 3/13 
                                                                                                      CAT ES 
                 Please do not                                                                        Request to Change
                 use staples.                                                                         Election Status 
CAT account number            FEIN/SSN                          Date of original consolidation Eff. date of change request 
                                                                    M M D    D  YY             M M D        D     YY 
Use only UPPERCASE letters. 
Reporting member's name 

Section 1 – Change in Status 
You must attach a complete organizational chart (including percentages of ownership between all entities) showing the 
business structure that refl ects its common owner for purposes of the CAT. The chart must comply with R.C. 5751.011, R.C. 
5751.012 and O.A.C. 5703-29-02. 
1. New taxpayer type: (Check only one) 
     
      Consolidated elected at 80%          Consolidated elected at 50%              Combined          Single
    By checking either consolidated box above, the group hereby elects to fi le a consolidated return. Any consolidated election will 
      remain in effect for eight calendar quarters and is automatically renewed unless cancelled by the registrant prior to the expiration 
      of the eight calendar quarters.
   Existing consolidated elected taxpayer groups wishing to cancel a previous election to consolidate should complete section 2 of 
      this form. 
       Please reference R.C. 5751.011 and 5751.012, as well as information releases CAT 2005-05 and CAT 2005-16 for a detailed 
      explanation of each fi ling status. 
   If changing to a consolidated elected or combined taxpayer group and adding members, attach CAT AR. 
2. If the group is a consolidated elected taxpayer group, does the group elect to include its non-U.S. entities? 
       Yes       No        N/A (currently do not have any non-U.S. entities)            Number of members
3. Please enter the total number of members, including the primary/reporting member.           , 
     Primary/reporting member's fi rst name                  M.I.  Last name 

Section 2 – Cancellation of Consolidated Election 
     By checking this box, the above-referenced taxpayer group hereby notifi es the tax commissioner that the group cancels its election 
     to consolidate. Such cancellation is not effective until the expiration of eight calendar quarters from the time of election or renewal 
     to consolidate. The group will become a combined taxpayer group, providing common ownership exists, pursuant to rule 5703-
     29-19. Please attach documentation indicating how each entity should now be registered. 
     Note: This section should only be answered if an existing consolidated elected taxpayer group wishes to notify the tax commissioner 
     of the cancellation of their previous consolidated election. I hereby declare the above to be true and correct to the best of my 
     knowledge and belief. 

SIGN HERE (required) 
I declare under penalty of perjury that I am the taxpayer or the taxpayer’s authorized agent having knowledge of the relevant facts in 
this matter to fi le this request to change election status. 

     Signature Date (MM/DD/YY) 

     Name Title 

Any member acquired or formed after the fi ling of the initial registration shall be included in the group. The group must notify the tax 
commissioner of any additions with either the next tax return fi led or form CAT AR. You must attach a complete organizational chart 
(including percentages of ownership between all entities) showing the business structure that refl ects its common owner for 
purposes of the CAT. The chart must comply with R.C. 5751.011, R.C. 5751.012 and O.A.C. 5703-29-02. 

                                                                                               Rev. 3/13 
                                                                                               CAT ES 
                                                                                               Request to Change
                Please do not 
                use staples.                                                                   Election Status 

Contact person:  The taxpayer will be represented in the matter by the following individual. Please attach a Declaration of Tax 
Representative (form TBOR 1), which can be found on the department’s Web site at tax.ohio.gov. 
Your fi rst name                      M.I.  Last name 

Home address (number and street) 

City                                                 State  ZIP code 

Telephone                        Fax 

Title                                E-mail 

                                     Please send this application to: 
                                     Ohio Department of Taxation
                                      CAT Division – CAT ES 
                                     P.O. Box 16158 
                                     Columbus, OH 43216-6158