REQUEST FOR RENAISSANCE ZONE CERTIFICATE OF
                          GOOD STANDING OR STATE TAX CLEARANCE RECORD
                          OFFICE OF STATE TAX COMMISSIONER
                          SFN 28220 (04-2020)                                                                               ND Tax Department 
                                                                                                                            Use Only
                                                                                                                              Approved
                                                                                                                              Not approved
Part 1 - Type of request
 This is a request for a: (Check applicable box)
     A.   Renaissance zone certificate of good standing (N.D.C.C. §§ 40-63-11 and 57-01-15.1)
         Check this box 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) 
         Check this box 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 (of Individual or Owner of Sole Proprietorship) Federal Employer Identification Number (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                         Or fax request to:  701.328.1942
                    Attn: Supervisor
                    Office of State Tax Commissioner          
                    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.

Request for Renaissance Zone Certificate of Good Standing or
State Tax Clearance Record
SFN 28220 (4-2020) page 2

Part 3 - Responsible Person Information

 Except for an individual or sole proprietorship (Part 2, Box 1), all taxpayers must complete Part 3. Enter the name and 
 social security number of any officer, partner, governor, or managing member who is responsible for the taxpayer’s tax 
 obligations. If there is more than one responsible person, include all all of them.

                         Name of Responsible Person                                 Social Security Number 

                          PRIVACY ACT NOTIFICATION
In compliance with the Privacy Act of 1974, disclosure of a social security number or Federal Employer Identification Number (FEIN) on this 
form is required under N.D.C.C. §§ 57-01-15 and 57-38-42, and will be used for tax reporting, identification, and administration of North 
Dakota tax laws. Disclosure is mandatory. Failure to provide the social security number or FEIN may delay or prevent the processing of this 
form.