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3 FINAL DRAFT 10/2/23 3
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8 2023 M4R, Minnesota Business Activity Report 8
Corporations are required to file Form M4R if they obtain any business from within Minnesota during the tax year. If you are registered with the Minnesota
9 Secretary of State’s Office to do business in this state, you are not required to file Form M4R. 9
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11 For Calendar Year Or fiscal year (enter beginning/ending dates) 11
12 Begins Ends 12
1999 01011966 01011966
13 Name of Corporation FEIN Minnesota Tax ID 13
14 NAME OF CORPORATIONXXXXXXXXXXXXXXXXXXX 0123456789 14
15 Mailing Address 0123456789Are you a member of a Do you make retail 15
unitary business? sales in Minnesota?
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17 MAILINGCity ADDRESSXXXXXXXXXXXX State ZIP Code Yes No Yes No 17
X X X X
18 CITYXXXXXXXXXXXXX MN 55555 18
19 Principal Office in Minnesota Principal Type of Business 19
20 FORMER NAME XXXXXXXXXXXXXXXXXXXXXX PRINCIPAL TYPE OF BUSINESS 20
21 Street Address Principal Product or Service 21
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23 STREETCity ADDRESS State ZIP Code PRINCIPALAmount of Minnesota Sales (wholesale or retail) or Receipts PRODUCT OR SERVICE 23
24 $ 24
CITYXXXXXXXXXXXXXXXXXXXX MN 55555 123456789000000000000000000
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26 Offices and other places of business in Minnesota. (Attach additional sheets if you need more room.) 26
27 Location Nature of Activity 27
28 LOCATION LOCATION LOCATION LOCATION NATURE OF ACTIVITY 28
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LOCATION LOCATION LOCATION LOCATION NATURE OF ACTIVITY
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32 LOCATION LOCATION LOCATION LOCATION NATURE OF ACTIVITY 32
33 Officers, employees, agents and representatives with activity in Minnesota. 33
34 (Attach a brief job description for each officer and class of employee.) 34
35 Title Number of Persons 35
36 TITLE NUMBER OF PERSONS 36
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38 TITLE NUMBER OF PERSONS 38
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40 On a separate sheet, explain all “yes” answers below in detail. During the period covered by the report, did the corporation: 40
41 Yes No 41
42 1 Own or lease tangible or intangible personal property or real property in Minnesota? 1 X X 42
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44 2 Employ or own any other assets in Minnesota? 2 X X 44
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46 3 Own or consign any merchandise located in Minnesota? 3 X X 46
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48 4 Own assets located in Minnesota that are leased to others? 4 X X 48
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50 5 Perform or contract any training, installation or repair work in Minnesota? 5 X X 50
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52 6 Perform or contract any warranty work in Minnesota? 6 X X 52
53 7 Derive any revenues from services performed by employees or entities 53
54 for persons or businesses located in Minnesota? 7 X X 54
55 8 Derive income from any source within Minnesota, including income from activities 55
56 conducted by subsidiaries, affiliated entities or partnerships? 8 X X 56
57 I certify that this report, including any accompanying material, is true, correct and complete to the best of my knowledge and belief. 57
58 Signature Title Date Direct Phone 58
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60 Signature of Preparer TITLE PTIN 11141966 Date 6515555555 Direct Phone 60
61 PTIN 11141966 6515555555 61
62 Mail to: Minnesota Department of Revenue, Mail Station 5130, 600 N. Robert St., St. Paul, MN 55146-5130 62
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