R -4310 (7/07)
                                Questionnaire To Assist In 
                                Determining Liability For
                                Corporation Income Tax Or
                                Corporation Franchise Tax

Company Name                    La Account Number                         FEIN

Address                         City                                      State                     ZIP

The following questions will assist us in determining whether your company is liable for Louisiana corporation income tax or 
corporation franchise tax.
Please complete this questionnaire, attach any additional information you wish to include, and return to the Louisiana Department 
of Revenue, Office Audit Division, Attn. ICFT Unit, PO Box 66362, Baton Rouge, Louisiana 70896-6362 or fax to (225) 219-2267.

A. Nexus Questionnaire
1.      Is this entity a corporation, a disregarded entity (such as a single-member LLC or QSSS),  or a partnership,
        LLC, or other entity that elects to file as a corporation for federal income tax purposes?                       ❏ ❏  Yes   ❏ ❏  No
        If yes, please explain.

2.      Does this company sell tangible personal property into Louisiana?                                                ❏ ❏  Yes   ❏ ❏  No
        If yes, fully describe the sales process, including whether sales personnel, technical personnel or independ-
        ent representatives come into Louisiana for any reason related to the sales. Also, complete Part B.

3.      Fully describe any types of services that are performed by this company in Louisiana or for or on behalf of an
        entity in Louisiana including the frequency and duration of the performance of the services.

4.      Fully describe any other trade or business that is conducted in Louisiana or for or on behalf of an entity in
        Louisiana including the frequency and duration of the conduct of the trade or business.

5.      Does this company license any type of intangible right to any entity that uses the right in Louisiana or that has
        customers in Louisiana?                                                                                          ❏ ❏  Yes   ❏ ❏  No
        Please explain. 
6.      What is the approximate number of Louisiana customers and the type or class of customers to whom 
        your products are sold, for whom your services are provided, or for whom your other type of trade or business
        is conducted?

7.      Please describe any other connection this company has to Louisiana, including transporting or delivering
        products or merchandise into or through the state or otherwise entering the state. Please include the 
        frequency and duration or other appropriate measurement of the extent of your connection to this state.

B. Public Law 86-272 Questionnaire—To be completed by companies with sales into Louisiana
1. Does this company:
          a.     Maintain an office or warehouse in Louisiana?                                           ❏ ❏  Yes ❏ ❏  No
          b.     Maintain stocks of merchandise, inventories, or samples, including samples used by 
                 sales personnel, in Louisiana?                                                          ❏ ❏  Yes ❏ ❏  No

          c.     Ship merchandise into Louisiana on consignment?                                         ❏ ❏  Yes ❏ ❏  No

          d.     Provide or reimburse for office space and related expenses for sales 
                 personnel in Louisiana?                                                                 ❏ ❏  Yes ❏ ❏  No

          e.     Furnish automobiles for use by sales personnel?                                         ❏ ❏  Yes ❏ ❏  No

2. Do your Louisiana sales personnel:
          a.     Work in states other than Louisiana?                                                    ❏ ❏  Yes ❏ ❏  No
                 If so, what is the approximate percentage of their time in 
                 Louisiana and outside Louisiana?

          b.     Assist your customers or users with warranty or damage claims?                          ❏ ❏  Yes ❏ ❏  No

          c.     Assist in the installation or operation of your 
                 products actually or in a supervisory capacity? (Sales or technical personnel)          ❏ ❏  Yes ❏ ❏  No

          d.     Collect delinquent accounts?                                                            ❏ ❏  Yes ❏ ❏  No
                 If no, how are they collected? 

3. What is the number of sales personnel in Louisiana each year?  
          a.     Are any sales personnel residents of Louisiana?                                         ❏ ❏  Yes ❏ ❏  No

          b.     What is the total annual compensation paid to sales personnel 
                 in Louisiana in each of the past three years? 

4. Is any merchandise shipped into Louisiana by company-owned or leased vehicles?                        ❏ ❏  Yes ❏ ❏  No
          If yes, how often?

5. Describe the products your company provides to Louisiana customers.

6. What is the amount of gross sales of products to Louisiana
   customers for each of the past three years?

7. Does your company provide any services or conduct any other trade or business in Louisiana other than 
   the sale of tangible personal property?                                                               ❏ ❏  Yes ❏ ❏  No

Name of person completing the questionnaire                      Title

Signature                                                        Date (MM/DD/YYYY)

Telephone Number                                                 Email address