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                     Audit Division 
                     P.O. Box 183014 
                     Columbus, OH 43218-3014 

                            Application for an Ohio Direct Payment Permit 
 The undersigned consumer hereby makes application pursuant to Ohio Revised Code (R.C.) section 5739.031 for authority to pay the 
 sales tax levied by R.C. sections 5739.02, 5739.021, 5739.023 and 5739.026, and the use tax levied under R.C. sections 5741.02,           
 5741.021, 5741.022 and 5741.023. 
 Please type or print clearly. Please complete all sections or the application may be denied. 

   1. Legal entity name                                              Trade name 
   2. Tax return mailing address 
   3. Person to contact regarding application (include telephone no. and e-mail address) 

   4. Federal employer identification number, or if none assigned for reporting federal taxes, please enter your Social Security number. 

     FEIN                                                                 Social Security number 
   5. Check whether business operates as:       Sole proprietor      Partnership/LLP          C corporation     Fiduciary                  
  
        Limited liability company    S corporation 
   6. If it is a partnership/LLP or limited liability company, provide the names and addresses of the partners or members: 
                   
     Name                            Street address                             City                        State      ZIP code 
                                                                                 
     Name                            Street address                             City                        State      ZIP code 
                                                                                 
     Name                            Street address                             City                        State      ZIP code 
     If more than three, attach a separate sheet listing the remaining partners/members’ information and check the box: 
   7. If it is a C corporation or an S corporation, provide the names and addresses of the officers: 

     Name/title                      Street address                             City                        State      ZIP code 
                                                                                 
     Name/title                      Street address                             City                        State      ZIP code 
                                                                                 
     Name/title                      Street address                             City                        State      ZIP code 
     If more than three, attach a separate sheet listing the remaining officers’ information and check the box:  
  
   8. Business description: 

   9. NAICS code          Estimated annual amount and number of taxable purchases:             
                                                                                                     $ Amount           # of transactions 
  10. Number of plants, divisions or other facilities to be included under this application: 
    Name                                                               Name 
    Address                                                            Address 
     If more than two, attach a separate sheet listing the information for the remaining locations and check the box: 

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 11. Number of plants, divisions or other facilities in Ohio not to be included under this application: 
  Name                                                          Name 
  Address                                                       Address 

   Direct payment #   98 -                                      Direct payment # 98 -
   Consumer’s use tax #  97 -                                   Consumer’s use tax #  97 -
  None                                                          None            
   If more than two, attach a separate sheet listing the information for the remaining locations and check the box: 
I hereby acknowledge these responsibilities and declare the information provided above to be true and correct and to the best of my 
knowledge and belief. 

   Signed                                                       Title 

   Date                                                         Phone number 

                              MAIL APPLICATION TO:                                           
                              Ohio Department of Taxation                
                              Attention: Audit Support                                         
                                                                Audit Division 
                                                             P.O. Box 183014                                                        
                              Columbus, Ohio 43218-3014 

                                                             UPS/Fed Ex, etc. 
                              4485 Northland Ridge Blvd. 
                              Columbus, OH 43229 
                              OR FAX APPLICATION TO: 
                              Ohio Department of Taxation             
                              Attention: Audit Support 
                                                                Audit Division 
                                                             (614) 387-2071 

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                                    Taxpayer Information Report 
  Instructions: Please complete all sections of this form with the requested information. 
  1. Ohio license/charter number (issued by the Ohio Secretary of State): 
  2. Check the box for each type of Ohio tax return fi led. In addition, provide the Ohio account number for each type of tax (attach a sepa-
  rate list if there are numerous accounts). 
  Tax   Type                                 Ohio Account Number                           Effective Date Date Closed 
  
  Sales Tax/Seller’s Use                                       
                                                                                             
  Consumer’s Use/Direct Pay                                    
                                                                                             
  Financial Institution                                        
                                                                                             
  Petroleum Activities                                          
                                                                                             
    Pass-through Entity (use FEIN)                                                           
                                                                                             
  Employer Withholding                                         
                                                                                             
    Individual Income (use SSN)                                                             
                                                                                             
  Commercial Activity                                          

  3. Provide a list of all entities where the taxpayer, directly or indirectly, (i) owns more than 50% of the voting stock of a corporation, or 
  (ii) has more than a 5% ownership interest in a pass-through entity, that is conducting business in Ohio (attach a separate list if more 
  space is needed). 
                        Entity Name                             FEIN                                      % of Ownership
                                                            
4. Provide a list of all entities which, directly or indirectly, (i) own more than 50% of the taxpayer’s voting stock, or (ii) have more than a 
  5% ownership interest in the taxpayer that is a pass-through entity (attach a separate list if more space is needed). 
                        Entity Name                             FEIN                                      % of Ownership 

5. Has the taxpayer fi led for protection under a U.S. Bankruptcy Court? Yes No 
  If yes, provide the date of filing 

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                                          Responsible Party Questionnaire 
We ask that each individual who was either: 1) an offi cer, member, manager or trustee; or 2) an employee (having control or supervision 
of or charged with the responsibility of fi ling returns and making payment) of the business entity complete this questionnaire. 
1. Answer the following questions. If additional space is necessary, attach additional sheets. 

Who is responsible for the overall fiscal re- Who prepares Ohio business tax reports/  Who has the authority to sign checks to 
sponsibilities?                              returns?                                   pay for business tax liabilities? 

Who actually performs the execution of the  Who assigns the responsibility to fi le Ohio  Who actually signs checks to pay for busi-
overall fi scal responsibilities?             business tax reports/returns?              ness tax liabilities? 

Who has the authority to prepare Ohio  Who actually fi les Ohio business tax re-         Who assigns the responsibility to sign 
business tax reports/returns?                ports/returns?                             Ohio business tax returns/reports? 

Who has the authority to assign the re-      Who has the responsibility for retaining,  Who exercises management control or au-
sponsibility for exercising management  directing or otherwise exercising control  thority over employees who were respon-
control or authority over employees who  over outside accountants, bookkeepers,  sible for preparing, signing or fi ling Ohio 
are responsible for preparing, signing or  or other persons who are charged with fil-    business tax reports/returns? 
  filing Ohio business tax reports/returns?   ing the Ohio business tax reports/returns? 

2. Provide a list of all shareholders or members that owned more than 5% of the value of the business including their Social Security 
number and home address. 

Individual / Shareholder /Member  SSN                                                          Home Address

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