Department of Taxation and Finance

                                    Business Contact and                                                                   DTF-17.1(4/16)
                                    Responsible Person Questionnaire

                     Retain a copy of this form for your records for each business contact or responsible person.

Who should complete this questionnaire
Any officer, partner, member, shareholder, or employee who is considered a business contact of the business applying for a sales tax Certificate of 
Authority should complete the Business contact information  section below. Also, a business contact who is a responsible person should also complete 
the Responsible person information section on page 2.

Responsible person
A responsible person generally includes anyone who does any of the following:
•  is actively involved in operating the business on a daily basis
•  is involved in deciding which financial obligations are paid
•  is involved in personnel activity (such as hiring or firing employees)
•  has check signing authority
•  prepares tax returns
•  has authority over business decisions
•  is a tax manager or general manager
In addition, certain owners, officers, partners, and members of limited liability companies (LLCs) are automatically considered responsible persons. To 
determine who is considered a business contact or responsible person, see the table below.

Entity type                         Business contacts                                        Responsible persons?
Individual (sole proprietor)        Owner                                                    Yes

Partnership, limited                All general partners                                     Yes
partnership (LP), or 
limited liability partnership (LLP) Any limited partner who:                                 Yes, if the limited partner does any of the following:
                                    •  actively runs the business, or                        •  is actively involved in operating the business on a daily 
                                    •  has at least 20% ownership or profit distribution     basis
                                    percentage                                               •  is involved in deciding which financial obligations are 
                                                                                             paid
                                                                                             •  is involved in personnel activity (such as hiring or firing 
                                                                                             employees)
                                                                                             •  has check signing authority
                                                                                             •  prepares tax returns
                                                                                             •  has authority over business decisions
                                                                                             •  is a tax manager or general manager
LLC                                 All members                                              Yes
                                    Appointed manager (if a manager-managed LLC)
Corporation                         CEO                                                      Yes, if the corporate officer or shareholder does any of 
                                    CFO                                                      the following:
                                                                                             •  is actively involved in operating the business on a daily 
                                    President                                                basis
                                                                                             •  is involved in deciding which financial obligations are 
                                    Vice President                                           paid
                                    Treasurer                                                •  is involved in personnel activity (such as hiring or firing 
                                                                                             employees)
                                    Secretary                                                •  has check signing authority
                                                                                             •  prepares tax returns
                                                                                             •  has authority over business decisions
                                                                                             •  is a tax manager or general manager
                                    Any shareholder who has at least 20% ownership or profit Yes, if the shareholder:
                                    distribution interest.                                   •  does any of the following (regardless of the amount of 
                                                                                             ownership or profit distribution interest):
                                                                                             –  is actively involved in operating the business on a 
                                                                                                daily basis
                                                                                             –  is involved in deciding which financial obligations are 
                                                                                                paid
                                                                                             –  is involved in personnel activity (such as hiring or 
                                                                                                firing employees)
                                                                                             –  has check signing authority
                                                                                             –  prepares tax returns
                                                                                             –  has authority over business decisions
                                                                                             –  is a tax manager or general manager
                                                                                             •  owns more than 50% of the voting stock of the 
                                                                                             corporation

Page 2 of 2  DTF-17.1 (4/16)

Business contact information
  Name (first, middle initial, last, suffix)                                                         Business title                                Date of birth (mm/dd/yyyy) 
                                                                                                                                                      /                                                    /            
  Home address (number and street; not a PO Box)  City                                               U.S. state/Canadian province ZIP/Postal code     Country
  Home phone number                              Ownership percentage except for                                    Profit distribution percentage, if different
 (      )                                        government entities, trusts, and estates:                          than ownership percentage:
 E-mail address
                                                                                                        If you are a responsible person, complete the Responsible person
   Are you a responsible person? ..............................................................  Yes No information section.

Responsible person information (Mark an  Xin the                  Yes or No box for each question below.)
 SSN                                         Country of residence                                       Effective date of assuming 
                                                                                                        responsibility                                /          /
 Partnerships, LPs, LLPs, and LLCs: Have you been designated as a tax matters partner or as the person responsible for
 tax issues? .......................................................................................................................................................................................   Yes  No
 Manager-managed LLC: Are you the appointed manager? ...........................................................................................................   Yes                                     No
 Will you be actively involved in operating this business on a daily basis? .......................................................................................   Yes                                  No
 Will you be involved in deciding which financial obligations are paid? .............................................................................................   Yes                                No
 Will you be involved in personnel activity (such as hiring or firing)? ................................................................................................   Yes                             No
 Primary duties - You must mark Yes for at least one of the business duties listed below:
 • Will you have check signing authority? ........................................................................................................................................   Yes                   No
 • Will you prepare tax returns?  ......................................................................................................................................................   Yes             No
 • Will you have authority over business decisions?  .......................................................................................................................   Yes                         No
 • Are you a tax manager or general manager? ..............................................................................................................................   Yes                          No
 Do you have any open, unsatisfied judgments, injunctions, or liens in effect today? ......................................................................   Yes                                          No
 Do you have any felony, misdemeanor, and/or administrative charges currently pending? ............................................................   Yes                                                  No
 At any time within the last five years, have there been any judgments, injunctions, or liens issued against you? ..............................   Yes                                                     No
 At any time within the last five years, have you had any permit, license, concession, franchise, or lease terminated for 
 cause or revoked for any reason? ...................................................................................................................................................   Yes                No
 At any time within the last five years, have you been investigated by any governmental or quasi-governmental agency, 
 including but not limited to federal, state, and local regulatory agencies?  ......................................................................................   Yes                                 No
 At any time within the last five years, have you been convicted of a misdemeanor and/or found in violation of any 
 administrative, statutory, or regulatory provisions? ..........................................................................................................................   Yes                     No 
 At any time within the last five years, have you had any sanction imposed as a result of a judicial, regulatory, or 
 administrative proceeding with respect to any license, permit, concession, franchise, or lease? ....................................................   Yes                                                No
 At any time within the last five years, have you failed to file any applicable federal, state, or New York City tax return by 
 the applicable due date?  .................................................................................................................................................................   Yes         No
 At any time within the last five years, have you failed to pay any applicable taxes or assessed government charges by  
 the applicable due date?  .................................................................................................................................................................   Yes         No
 At any time within the past seven years, has any bankruptcy proceeding been initiated by or against you? ..................................   Yes                                                         No
 At any time within the last ten years, have you been convicted of a felony and/or any crime related to truthfulness and/or 
 business conduct? ...........................................................................................................................................................................   Yes       No

Retain a copy of this form for your records for each business contact or responsible person.