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REQUEST FOR RENAISSANCE ZONE CERTIFICATE OF
GOOD STANDING OR STATE TAX CLEARANCE RECORD
OFFICE OF STATE TAX COMMISSIONER
SFN 28220 (8-2023)
Tax Department
Use Only
Approved
Not approved
Part 1 - Type of request
This is a request for a: (Fill in applicable circle)
A. Renaissance zone certificate of good standing (N.D.C.C. §§ 40-63-11 and 57-01-15.1)
Fill in this circle if you need a certificate of good standing because you are applying for an income or property tax
exemption or income tax credit under the Renaissance Zone Program.
B. Non-renaissance zone property tax exemption state tax clearance record (N.D.C.C. § 57-01-15.1)
Fill in this circle if applying for one of the following property tax exemptions. Also check the exemption being claimed.
New or expanding business property tax exemption under N.D.C.C. Ch. 40-57.1.
Development or renewal area property tax exemption (tax increment financing) under N.D.C.C. Ch. 40-58.
Part 2 - Taxpayer information
Legal Name of Taxpayer (If a sole proprietorship, enter name of individual who owns the business.)
Trade or Doing Business as Name, if Different from Legal Name Above
Current Mailing Address City State ZIP Code
Type of Entity 6. Limited Liability Company (Filing as a Partnership)
1. Individual (or Sole Proprietorship) 7. Limited Liability Company (Filing as an S Corporation)
2. Regular (C) Corporation 8. Limited Liability Company (Treated as a Disregarded Entity) - Identify Owner Below:
3. Partnership (All Types) Owner’s Name: ___________________________________________________
4. Subchapter S Corporation Owner’s Social Security Number or FEIN: _______________________________
5. Estate or Trust 9. Other (Identify) _____________________________________________
Important: Except for an individual (or sole proprietorship), all taxpayers must complete Part 3 on page 2.
Social Security Number (Individual or Owner of Sole Proprietorship) FEIN (If a Sole Proprietorship, Enter FEIN if it has one)
Is taxpayer a newly created business this year? Yes No
If taxpayer is a business, what is the principal business activity? __________________________________________________________
Did taxpayer file a North Dakota income tax return for the most recent tax year? Yes No
(If a newly created business this year, skip this question.)
If no, explain __________________________________________________________________________________________
Does (or will) taxpayer sell tangible personal property or services for which North Dakota sales tax must be Yes No
collected from the customer?
If yes, has taxpayer applied for or obtained a North Dakota sales tax permit? Yes No
If no, explain ____________________________________________________________________________________________
Does (or will) taxpayer have employees whose wages are subject to North Dakota income tax withholding? Yes No
If yes, has taxpayer registered for North Dakota income tax withholding? Yes No
If no, explain ____________________________________________________________________________________________
Taxpayer’s Signature Date
Printed Name of Taxpayer Contact Telephone Number
Mail request to: Individual Income Tax Section Email request to: individualtax@nd.gov
Office of State Tax Commissioner Fax request to: 701-328-1942
600 E. Boulevard Ave.
Bismarck ND 58505-0599
Important: The renaissance zone certificate of good standing or state tax clearance record will only be sent to the
taxpayer or to the taxpayer’s designated representative shown on a North Dakota Form 500 attached to this form.
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