CORPORATE INFORMATION QUESTIONNAIRE 

1. Account No.                     Active   Inactive   Date                                  Preparer  
2. Corporate Name                                                                            Corporate I.D. No. 
DBA(s)
3. Period of Liability                                                                       Total of Liability $ 
4. Identity of Principal(s), Corporate Officer(s), and/or Stockholder(s):
A.  Name                                               Title                                             SSA No. 
 CDL No.                           % Stock             Period Involved 
 Address 
B.  Name                                               Title                                             SSA No. 
 CDL No.                           % Stock             Period Involved 
 Address  
C.  Name                                               Title                                             SSA No. 
 CDL No.                           % Stock             Period Involved 
 Address 
D.  Name                                               Title                                             SSA No. 
 CDL No.                           % Stock             Period Involved 
 Address  
5. Was State Disability Insurance/Personal Income Tax withheld?   Yes                         No 
6. Was it placed in a trust account?   Yes    No
Provide all bank names, addresses, and bank account numbers

7. Who prepared the quarterly tax returns/deposits?
8. Who signed returns/deposits?
9. Who signed payroll checks?
 10. Who signed business checks?
 11. Who had the final word as to what bills would be paid?
 12. Who was the signator(s) on the account(s)?
 13. Number of signatures required?
 14. Who managed and directed operations?
 15. Who hired/fired employees?
 16. Who supervised the employees?
 17. Who negotiated contract/business transactions?
 18. Who negotiated and guaranteed loans?
 19. What business expenses (including wages, loan payments, other taxes) were paid after the liability
became due?

                                          (See page 2 for additional comments)
DE 204 Rev. 5 (10-13) (INTERNET)                                               Page 1 of 2                        CU 

                                 CORPORATE INFORMATION QUESTIONNAIRE (CONT’D) 

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

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

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 No.                                          SSA No.                                                       CA Driver License No.  
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: 
SSA No.:                                                     CA Driver License No.: 

DE 204 Rev. 5 (10-13) (INTERNET)                                                                   Page 2 of 2