CORPORATE INFORMATION QUESTIONNAIRE

1. Account Number                        Active  Inactive    Date                Preparer 

2. Corporate Name                                        Corporate I.D. Number 
DBA(s)

3. Period of Liability                            Total of Liability $ 

4. Identity of Principal(s), Corporate Officer(s), and/or Stockholder(s):

A. Name                                  Title                            Last 4 Digits of SSN 
CA Driver License Number                              % Stock             Period Involved 
Address
B. Name                                  Title                            Last 4 Digits of SSN 
CA Driver License Number                              % Stock             Period Involved 
Address
C. Name                                  Title                            Last 4 Digits of SSN 
CA Driver License Number                              % Stock             Period Involved 
Address
D. Name                                  Title                            Last 4 Digits of SSN 
CA Driver License Number                              % Stock             Period Involved 
Address

5. Were you aware of the quarterly tax returns/deposits reporting requirements?
a. Yes   No
b. If no, then who was/were:

6. Were you aware of the due dates for quarterly tax returns/deposits?
a. Yes   No
b. If no, then who was/were:

7. Was State Disability Insurance/Personal Income Tax withheld?
a. Yes   No
b. If no, please explain why not:

8. Was it placed in a trust account?
a. Yes   No
b. If no, please explain why not:
Provide all bank names, addresses, and bank account numbers

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9. Is the company registered with e-Services for Business? Yes   No
a. If yes, list the Administrator and all authorized third-party/account managers by name and title.

b. Who authorized the above individual(s) access to the e-Services for Business?

c. If no, how are the quarterly tax returns/deposits submitted?

10.Who prepared the quarterly tax returns/deposits?

11.Whose signature was on the payroll checks?

12.Whose signature was on the business checks?

13.Who had the final word as to what bills would be paid?

14.a.  Who was authorized to sign on the account(s)?

b. Number of signatures required?

15.Who managed and directed operations?

16.Who hired/fired employees?

17.Who supervised the employees?

18.Who negotiated contracts/business transactions?

19.Who negotiated and guaranteed loans?

20.What business expenses (including wages, loan payments, other taxes) were paid after the liability became
due?

21.Did principal(s) receive any corporate funds, assets, wages, or loan repayments after this liability became due?
Yes  No
If yes, explain:

22.List names/titles, addresses, and phone numbers of individuals who could confirm the above information:

                                 (See page 3 for additional comments)

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                    CORPORATE INFORMATION QUESTIONNAIRE (CONTINUED)

I declare under penalty of perjury that the foregoing, to the best of my knowledge and belief, is true and 
correct:

Signature and Title of Preparer                                           Date 
Phone Number                     Last 4 Digits of SSN           CA Driver License Number 
Address 
In your own words, explain why the taxes were not paid using the Additional Comments section below. If there 
is not enough space provided, additional pages may be attached.

Additional Comments:

Section 1735 of the California Unemployment Insurance Code (CUIC) reads:

“Any officer, major stockholder, or other person, having charge of the affairs of a corporation or association, 
registered limited liability partnership or foreign limited liability partnership, or limited liability company 
employing unit, who willfully fails to pay contributions required by this division or withholdings required by 
Division 6 (commencing with section 13000) on the date on which they become delinquent, shall be personally 
liable for the amount of the contributions, withholdings, penalties, and interest due and unpaid by such 
employing unit. The director may assess such officer, stockholder, or other person for amount of such 
contributions, withholdings, penalties, and interest. The provisions of Article 8 (commencing with section 1126) 
and Article 9 (commencing with section 1176) of Chapter 4 of Part 1 apply to assessments made pursuant to this 
section. Sections 1221, 1222, 1223, and 1224 shall apply to assessments made pursuant to this section. With 
respect to such officer, stockholder, or other person, the director shall have all the collections remedies set forth 
in this chapter.”
This is to acknowledge that I have read and understand the above code section of the CUIC and have been 
provided an explanation of the investigation and assessment process.

Name                                                                      Date 
Phone Number (Work)                                                   (Home) 
Address 
Last 4 Digits of SSN              CA Driver License Number 

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