Form SS-4 (Rev. January 2009) Type or print clearly. Department of the Treasury Internal Revenue Service 8a 8c 9a Application for Employer Identification Number (For use by employers, corporations, partnerships, trusts, estates, churches, government agencies, Indian tribal entities, certain individuals, and others.) © © See separate instructions for each line. Keep a copy for your records. 1 Legal name of entity (or individual) for whom the EIN is being requested 2 Trade name of business (if different from name on line 1) 3 Executor, administrator, trustee, “care of” name 4a Mailing address (room, apt., suite no. and street, or P.O. box) 5a Street address (if different) (Do not enter a P.O. box.) 4b City, state, and ZIP code (if foreign, see instructions) 5b City, state, and ZIP code (if foreign, see instructions) 6 County and state where principal business is located 7a Name of principal officer, general partner, grantor, owner, or trustor Is this application for a limited liability company (LLC) (or a foreign equivalent)? Yes 7b SSN, ITIN, or EIN 8b If 8a is “Yes,” enter the number of © LLC members No No Estate (SSN of decedent) Partnership Plan administrator (TIN) Corporation (enter form number to be filed) 10 Yes If 8a is “Yes,” was the LLC organized in the United States? Type of entity (check only one box). Caution. If 8a is “Yes,” see the instructions for the correct box to check. Sole proprietor (SSN) 9b OMB No. 1545-0003 EIN © Trust (TIN of grantor) Personal service corporation National Guard State/local government Church or church-controlled organization Farmers’ cooperative Federal government/military Other nonprofit organization (specify) © Other (specify) © If a corporation, name the state or foreign country (if applicable) where incorporated Reason for applying (check only one box) Started new business (specify type) State REMIC Indian tribal governments/enterprises Group Exemption Number (GEN) if any © Foreign country Banking purpose (specify purpose) © © Changed type of organization (specify new type) © Purchased going business Hired employees (Check the box and see line 13.) Created a trust (specify type) © 11 Compliance with IRS withholding regulations Created a pension plan (specify type) © Other (specify) © Date business started or acquired (month, day, year). See instructions. 12 Closing month of accounting year 13 Highest number of employees expected in the next 12 months (enter -0- if none). 14 15 16 Do you expect your employment tax liability to be $1,000 or less in a full calendar year? Yes No (If you Agricultural Household Other expect to pay $4,000 or less in total wages in a full calendar year, you can mark “Yes.”) First date wages or annuities were paid (month, day, year). Note. If applicant is a withholding agent, enter date income will first be paid to © nonresident alien (month, day, year) Check one box that best describes the principal activity of your business. Construction 17 18 Rental & leasing Transportation & warehousing Finance & insurance Health care & social assistance Accommodation & food service Wholesale-agent/broker Retail Wholesale-other Real estate Manufacturing Other (specify) Indicate principal line of merchandise sold, specific construction work done, products produced, or services provided. Has the applicant entity shown on line 1 ever applied for and received an EIN? If “Yes,” write previous EIN here © Yes No Complete this section only if you want to authorize the named individual to receive the entity’s EIN and answer questions about the completion of this form. Third Party Designee Designee’s name Designee’s telephone number (include area code) Address and ZIP code Designee’s fax number (include area code) ( ( Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is true, correct, and complete. Name and title (type or print clearly) © ) ) Applicant’s telephone number (include area code) ( ) Applicant’s fax number (include area code) Signature © Date For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. © ( Cat. No. 16055N ) Form SS-4 (Rev. 1-2009) Form SS-4 (Rev. 1-2009) Page 2 Do I Need an EIN? File Form SS-4 if the applicant entity does not already have an EIN but is required to show an EIN on any return, statement, or other document.1 See also the separate instructions for each line on Form SS-4. IF the applicant... Started a new business AND... Hired (or will hire) employees, including household employees Does not already have an EIN Complete lines 1, 2, 4a–6, 7a–b (if applicable), 8a, 8b–c (if applicable), 9a, 9b (if applicable), 10–18. Opened a bank account Needs an EIN for banking purposes only Complete lines 1–5b, 7a–b (if applicable), 8a, 8b–c (if applicable), 9a, 9b (if applicable), 10, and 18. Changed type of organization Either the legal character of the organization or its ownership changed (for example, you incorporate a sole proprietorship or form a partnership) 2 Complete lines 1–18 (as applicable). Does not already have an EIN The trust is other than a grantor trust or an IRA trust 4 Complete lines 1–18 (as applicable). Complete lines 1–18 (as applicable). Created a pension plan as a plan administrator 5 Needs an EIN for reporting purposes Complete lines 1, 3, 4a–5b, 9a, 10, and 18. Is a foreign person needing an EIN to comply with IRS withholding regulations Needs an EIN to complete a Form W-8 (other than Form W-8ECI), avoid withholding on portfolio assets, or claim tax treaty benefits 6 Complete lines 1–5b, 7a–b (SSN or ITIN optional), 8a, 8b–c (if applicable), 9a, 9b (if applicable), 10, and 18. Is administering an estate Needs an EIN to report estate income on Form 1041 Complete lines 1–6, 9a, 10–12, 13–17 (if applicable), and 18. Is a withholding agent for taxes on non-wage income paid to an alien (i.e., individual, corporation, or partnership, etc.) Is a state or local agency Is an agent, broker, fiduciary, manager, tenant, or spouse who is required to file Form 1042, Annual Withholding Tax Return for U.S. Source Income of Foreign Persons Complete lines 1, 2, 3 (if applicable), 4a–5b, 7a–b (if applicable), 8a, 8b–c (if applicable), 9a, 9b (if applicable), 10, and 18. Serves as a tax reporting agent for public assistance recipients under Rev. Proc. 80-4, 1980-1 C.B. 581 7 Complete lines 1, 2, 4a–5b, 9a, 10, and 18. Is a single-member LLC Needs an EIN to file Form 8832, Classification Election, for filing employment tax returns and excise tax returns, or for state reporting purposes 8 Complete lines 1–18 (as applicable). Is an S corporation Needs an EIN to file Form 2553, Election by a Small Business Corporation 9 Complete lines 1–18 (as applicable). Purchased a going business Created a trust Does not currently have (nor expect to have) employees 3 THEN... Complete lines 1, 2, 4a–8a, 8b–c (if applicable), 9a, 9b (if applicable), and 10–14 and 16–18. 1 For example, a sole proprietorship or self-employed farmer who establishes a qualified retirement plan, or is required to file excise, employment, alcohol, tobacco, or firearms returns, must have an EIN. A partnership, corporation, REMIC (real estate mortgage investment conduit), nonprofit organization (church, club, etc.), or farmers’ cooperative must use an EIN for any tax-related purpose even if the entity does not have employees. 2 However, do not apply for a new EIN if the existing entity only (a) changed its business name, (b) elected on Form 8832 to change the way it is taxed (or is covered by the default rules), or (c) terminated its partnership status because at least 50% of the total interests in partnership capital and profits were sold or exchanged within a 12-month period. The EIN of the terminated partnership should continue to be used. See Regulations section 301.6109-1(d)(2)(iii). Do not use the EIN of the prior business unless you became the “owner” of a corporation by acquiring its stock. 3 4 However, grantor trusts that do not file using Optional Method 1 and IRA trusts that are required to file Form 990-T, Exempt Organization Business Income Tax Return, must have an EIN. For more information on grantor trusts, see the Instructions for Form 1041. 5 A plan administrator is the person or group of persons specified as the administrator by the instrument under which the plan is operated. 6 Entities applying to be a Qualified Intermediary (QI) need a QI-EIN even if they already have an EIN. See Rev. Proc. 2000-12. 7 See also Household employer on page 4 of the instructions. Note. State or local agencies may need an EIN for other reasons, for example, hired employees. 8 See Disregarded entities on page 4 of the instructions for details on completing Form SS-4 for an LLC. 9 An existing corporation that is electing or revoking S corporation status should use its previously-assigned EIN. R-16019 (5/08) CR1 Application for Louisiana Revenue Account Number P.O. Box 201 Baton Rouge, LA 70821-0201 (225) 219-7318 For office use only. Date of application 1. A. Sales/ Use B. ■ Louisiana General Sales Tax C. ■ Statewide Hotel/Motel D. ■ Jefferson Parish Hotel/Motel E. ■ Orleans Parish Hotel/Motel ■ Orleans Parish Restaurant ■ N.O. Airport Food Establishments ■ Motor Vehicle Lessors/Rentors ■ Withholding F. ■ Vehicle Rental Excise ■ Severance Oil and Gas Classification ■ Taxpayer Only ■ Producer Only ■ Producer/Taxpayer ■ Other _________________________ _________________________ _________________________ 2. Reason for applying A. ■ Started new business C. ■ Other (specify) B. ■ Purchased ongoing business: Name of previous owner 3. Indicate the account number you use for each tax filed with the Louisiana Department of Revenue. LA Corp. Tax Number None ■ LA Sales Tax Number None ■ LA Excise Taxes Number LA Withholding Tax Number None ■ 4. A. Legal name(s) B. Trade name of business 5. A. Business location address (NO P.O. Box or General Delivery) B. City and state 6. A. Address for receiving tax forms and correspondence (If same location, write “same”.) B. 7. Type of organization: A. ■ Individual 8. U.S. NAICS Code 9. (required) LA Severance Tax Number None ■ LA Natural Resource Number None ■ Telephone ( ) ___________________ C. ZIP C. City and State B. ■ Partnership ZIP D. ( C. ■ Corporation ) E. ■ Additional mailing address(es) attached Telephone D. ■ Governmental E. ■ Nonprofit F.■ Other Federal Employer None ■ ID Number 10. If sole owner (individual): Name None ■ SSN Telephone ( Home address 11. If corporation or partner- Name ship: name, title, Social Security Number, home Address address, and telephone number of officers or Name partners Title ) SSN ( ) _________________ Telephone ( ) _________________ Telephone Title SSN Address 12. A. Louisiana Charter Number (if known) _________________________ B. State of incorporation (if not Louisiana) ___________________ 13. Permits -Sellers of liquor, beer, or wine (wholesale or retail), must obtain a permit from the Office of Alcohol and Tobacco Control. A permit from the Louisiana State Police Gaming Division must be obtained by sellers of lottery tickets or operators of video poker games. Indicate permit number(s) that you currently hold. Lottery Permit Number B. Expiration Month/Year________________________________ A. Alcohol Permit Number Expiration Month/Year________________________________ VPG Permit Number Expiration Month/Year_ ___________________________ 14. A. Corporation Income/Franchise: Date charter filed with Louisiana Secretary of State Mo. Day Yr. Domestic B. Foreign Fiscal Month C. 15. Sales or Use Tax: Date business begins sales operations from this location 16. Withholding Tax: (See instructions.) Select filing frequency. ■ quarterly ■ monthly ■ semi-monthly 17. Severance Tax: Select filing frequency. ■ quarterly ■ monthly ■ 45-day 18. Description of business: (required) Signature of applicant I affirm that the information given on this application is true and Signature of preparer correct. Title Date (mm/dd/yyyy) 1500 For Office Use Only Account Number ____________________ CITY OF BATON ROUGE PARISH OF EAST BATON ROUGE P.O. BOX 2590 BATON ROUGE, LA 70821 PHONE: (225) 389-3084 FAX: (225) 389-5369 Email: [email protected] Revised 05/28/2008 Louisiana Tax Number Federal ID Number Description of Business NAIC Number For Office Use Only Application Number ____________________ (See List of Business Classes) LEGAL NAME OF BUSINESS TRADE NAME OF BUSINESS PHYSICAL LOCATION (NOT a P.O. Box) Business Telephone No. (___)_______________ MAILING ADDRESS APPLICATION FOR: DATE IN BUSINESS: _____/_____/_____ Sales Tax Registration Occupational License Tax Hotel Motel Tax Insurance Premium Tax Gross Receipts Tax Other _________________ REASON FOR APPLYING: New Business Purchased Existing Business? Previous Owner: Merger Trade Name of Previous Owner/Business: Additional Information Previous Account Number: Change Other BUSINESS LOCATION: City Limits of Baton Rouge Unincorporated Parish of EBR City Limits of Baker City Limits of Central City Limits of Zachary Business Located Outside of EBR FOR OCCUPATIONAL LICENSE ONLY FOR OFFICE USE ONLY Business opened on or prior to June 30 of current year (Minimum Payment) $50 due Business opened on or after July 1 of current year (Minimum Payment) $25 due Flat Fee Business $100 / $200 / $250 Hotel / Nursing Home / Rooms ________ (# of rooms) x $2 per room = $ Security Deposit Due? ___Yes ___No Deposit Due $ If business opened more than 30 days ago: Tax Due for First Year of Business Enter Gross Receipts (1st 30 days in business) $ Less Allowable Deductions (See List below Tax Tables on attached sheet) $ Tax Basis (Total Gross Receipts less Total Deductions) $ Multiply Tax Basis by # of months in business (Any month open at least 15 days) $ Tax Due (Based on Tax Table attached) $ Penalty $ Interest $ Total Due $ *99999999* ABC Account Clearance Issued Contact Phone: CONTACT PERSON: Contact Fax: Contact E-mail: TYPE OF ORGANIZATION (Ownership) – Please attach a copy of your charter Individual Partnership Corporation LLC LLP IF an Individual: (Attach valid photo ID) Owner’s Name Owner’s Address IF a Corporation, LLC, LLP, or Partnership: (Attach additional names if necessary) Owner’s SS# E-mail Address Officer / Manager / Partners Name Title Home Address Non-Profit Governmental Other Telephone Number Web Site Agent for Service of Process: Name Address This will affirm that the statements made herein are true and correct to the best of my knowledge: Signature of Applicant or Owner Title Signature of Preparer Date Please make checks payable to Parish and City Treasurer FOR OFFICE USE ONLY LOCATION/DOMICILE (Circle One) 0001 City of Baton Rouge / EBR Sch Bd 0002 EBR Parish / EBR Sch Bd 0003 City of Baker / Baker Sch Bd 0004 City of Zachary / Zachary Sch Bd 0005 EBR Parish / Zachary Sch Bd 0006 City of Baker / EBR Sch Bd 0007 City of Central / Central Sch Bd 0008 EBR Parish / Central Sch Bd 0009 Outside EBR Parish 0010 Outside Louisiana GROUP (Circle One) 0000 Not Assigned 0001 Mall of Louisiana 0002 Cortana Mall 0003 Major Chemical & Manuf 0004 Hammond Aire 0005 Downtown Development CATEGORY (Circle One) 0900 Walk-in Registration 0901 Mail-in Registration 0902 Electronic Registration 0903 Issue to Post 0904 Revenue Inspector 0905 Audit Registration 0906 File Conversion A B D F C E G H FILING FREQUENCY M Monthy Q Quarterly O One Time Sale X Irregular Filer L Annual (License Only) CLASS (Circle One) 0100 Public Utility Only 0101 Public Utility / OLT 0102 Public Utility / STX 0103 Public Utility / STX / OLT 0200 IPT 0201 IPT / STX 0300 HM / Rms 0301 HM / Rms / STX 0302 HM / Rms / STX / OLT 0303 HM / Rms / STX / OLT / ABC 0304 HM 0305 HM / STX 0400 Nursing Home / Rms 0401 Nursing Home / Rms / STX 0500 Amusement Only 0501 Amusement / STX 0502 Amusement / STX / OLT 0503 Amusement / STX / OLT / ABC 0600 STX Only 0601 STX / OLT 0602 STX / OLT / ABC 0700 OLT Only ACCOUNT TYPE (Circle One) 1520 Retail Mdse/Service/Rental/Etc. 1521 Airline 1522 Travel Agency 1523 Nursing Home 1525 Retail Dealer 1530 Retail Dealers In Motor Fuels 1540 Pawn Broker 1601 Retail Dealer – Institutional Consumers 1610 Wholesale Dealer 1611 Bulk Petro 1612 Wholesale – Motor Vehicle 1622 Building Materials 1710 Finance 1820 Commissioned Services 1822 Real Estate Broker 2010 Investment Banking 2020 Itinerant Vendor (Agricultural & Seafood) 2021 Itinerant Vendor (Parades & Food Vendor) 2022 Promoter 2023 Rolling Vendor 2060 Special Events 2070 Museum for Profit / Transient 2090 Professional 2640 Retail Autos 2710 Contractor 6000 Insurance Company 7001 Public Utilities-Gross Receipts 9999 No Occupational License Account Set Up By: Payment Received By: NAIC PLEASE CHOOSE A BUSINESS CATEGORY THAT BEST DESCRIBES YOUR BUSINESS ACTIVITY CATEGORY DESCRIPTION DETAIL DESCRIPTION 111000 112000 211000 212000 236000 237000 238000 311000 312000 314000 322000 324000 325000 326000 339000 423000 424000 441000 442000 443000 444000 445000 446000 447000 448000 451000 453000 454000 482000 484000 485000 493000 512000 515000 517000 518000 521000 524000 531000 532000 541000 551000 611000 621000 622000 623000 711000 712000 713000 721000 722000 811000 812000 813000 815000 5/28/2008 Agriculture, Forestry, Fishing Agriculture, Forestry, Fishing Mining Mining Construction Construction Construction Manufacturing Manufacturing Manufacturing Manufacturing Manufacturing Manufacturing Manufacturing Manufacturing Wholesale Trade Wholesale Trade Retail Trade Retail Trade Retail Trade Retail Trade Retail Trade Retail Trade Retail Trade Retail Trade Retail Trade Retail Trade Retail Trade Transportation & Warehouse Transportation & Warehouse Transportation & Warehouse Transportation & Warehouse Information Information Information Information Finance & Insurance Finance & Insurance Finance & Insurance Finance & Insurance Professional, Scientific & Technology Management of Companies Educational Services Health Care & Social Assistance Health Care & Social Assistance Health Care & Social Assistance Arts, Entertainment & Recreation Arts, Entertainment & Recreation Arts, Entertainment & Recreation Accommodation & Food Service Accommodation & Food Service Other Services Other Services Other Services Other Services Crop Production Animal Production Oil & Gas Production Mining (Except Oil & Gas) Construction of Buildings Heavy & Civil Engineering Construction Specialty Trade Contractors Food Manufacturing Beverage & Tobacco Product Manufacturing Textile Product Mills Paper Manufacturing Petroleum & Coal Products Manufacturing Chemical Manufacturing Plastics & Rubber Product Manufacturing Miscellaneous Manufacturing Merchant Wholesalers, Durable Goods Merchant Wholesalers, Nondurable Goods Motor Vehicle & Parts Dealer Furniture & Home Furnishing Stores Electronic & Appliance Stores Building Material & Garden Equip/Supplies Food & Beverage Health & Personal Care Stores Gasoline Stations Clothing & Clothing Accessories Stores Sporting Goods, Hobby, Book/Music Stores Miscellaneous Store Retailers Nonstore Retailers Rail Transportation Truck Transportation Transit & Ground Passenger Transportation Warehousing & Storage Motion Picture & Sound Recording Industries Broadcasting (except internet) Telecommunications, Internet Service Providers Portals & Data Processing Services Monetary Authorities Insurance Carriers & Related Activities Real Estate Rental & Leasing Services Professional, Scientific & Technology Management of Companies & Enterprises Educational Services Ambulatory Health Care Services Hospitals Nursing & Residential Care Facilities Performing Arts, Spectator Sports & Related Industries Museums, Historical Sites, & Similar Institutions Amusement, Gambling & Recreation Industries Accommodation Food Services & Drinking Places Repair & Maintenance Personal & Laundry Services Religious, Grantmaking, Civic, Professional & Similar Services Miscellaneous Other Services Jay Dardenne ARTICLES OF INCORPORATION Secretary of State (R.S. 12:24) Domestic Business Corporation Enclose $60.00 filing fee Make remittance payable to Secretary of State Do Not Send Cash Return to: Commercial Division P. O. Box 94125 Baton Rouge, LA 70804-9125 Phone (225) 925-4704 Web Site: www.sos.louisiana.gov STATE OF ________________________________ PARISH/COUNTY OF _________________________ 1. The name of this corporation is:_______________________________________________________________________ 2. This corporation is formed for the purpose of : (check one) ( ) Engaging in any lawful activity for which corporations may be formed. ( ) _____________________________________________________________________________ (use for limiting corporate activity) 3. The duration of this corporation is: (may be perpetual) ____________________________________________________ 4. The aggregate number of shares which the corporation shall have authority to issue is :___________________________ 5. The shares shall consist of one class only and the par value of each share is ____________________________________ (shares may be without par value) per share. 6. The full name and post office address of each incorporator is : ______________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 7. Other provisions: _________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 8. The corporation’s federal tax identification number is: ____________________________________________________ Incorporator(s) Signature: ________________________________________________________ ________________________________________________________ ________________________________________________________ On this _____ day of ______________________________200__, before me, personally appeared ____________________ ____________________________________________, to me known to be the person described in and who executed the foregoing instrument, and acknowledged that he executed it as his free act and deed. NOTARY NAME MUST BE TYPED OR PRINTED WITH NOTARY # Notary Signature SS399 Rev. 10/06 (See instructions on back) INSTRUCTIONS NOTE: A corporation is a complex form of business structure. This form contains only the minimum provisions required by law to be set forth in Articles of Incorporation. Additional provisions may be advisable or necessary, depending on the specific needs of each corporation. Consideration should be given to the advantages and disadvantages of incorporating, and the legal and tax consequences. You are strongly advised to seek legal advice from an attorney and tax and other business advice from an accountant. 1. File the Articles of Incorporation, and the Domestic Corporation Initial Report (form 341) which contains an agent affidavit and the requisite $60 filing fee with the Secretary of State’s office. 2. The Articles of Incorporation and the Initial Report may be delivered to the Secretary of State’s office in advance, for filing as of any specified date (and any given time on such date) within thirty days after the date of delivery. Requests should be made in writing and must be submitted along with the Articles of Incorporation and the Initial Report. 3. The Articles of Incorporation cannot be accepted for filing unless an Initial Report form (341) is also filed. Upon filing with our office, you will receive a certified copy of the Articles and a Certificate of Incorporation. Within thirty (30) days after filing the Articles of Incorporation with the Secretary of State’s office, a multiple original of the Articles and the Initial Report (or a copy of each certified by the Secretary of State), and a copy of the Certificate of Incorporation must be filed with the office of the recorder of mortgages in the parish where the corporation’s registered office is located. 4. Please call the Internal Revenue Service at (901) 546-3920 for information to obtain a corporation’s federal tax identification number prior to incorporation. 5. If the Articles of Incorporation are filed within five (5) working days (exclusive of legal holidays) after acknowledgement, the corporate existence shall begin as of the time of such acknowledgement. Jay Dardenne Secretary of State DOMESTIC BUSINESS CORPORATION INITIAL REPORT (R.S. 12:25 AND 12:101) 1. The name of this corporation is: 2. The location and municipal address (not a P.O. Box only) of this corporation’s registered office: 3. The full name and municipal address (not a P. O. Box only) of each of this corporation’s registered agent(s) is/are: 4. The names and municipal address (not a P.O. Box only) of the first directors are: Incorporator(s) signature(s) AGENT’S AFFIDAVIT AND ACKNOWLEDGEMENT OF ACCEPTANCE I hereby acknowledge and accept the appointment of registered agent for and on behalf of the above named corporation. Registered agent(s) signature(s): Sworn to and subscribed before me, the undersigned Notary Public, on this date: NOTARY NAME MUST BE TYPED OR PRINTED WITH NOTARY # Notary Signature SS341 Rev. 10/06 (See instructions on back) INSTRUCTIONS 1. An Initial Report must be completed and filed with the Articles of Incorporation of a Domestic Business Corporation. 2. If no directors have been selected when the Initial Report and Articles of Incorporation are filed, a Supplemental Report, setting forth their names and addresses must be filed in accordance with R.S. 12:25. 3. The Affidavit of Acknowledgement and Acceptance contained on the bottom of this form must be signed by each registered agent before a notary public. NOTE: Upon filing the Articles of Incorporation and Initial Report with our office, you will receive certified copies of both documents and a Certificate of Incorporation. Within thirty (30) days after filing with the Secretary of State’s office, a multiple original of the Articles and the Initial Report (or a copy of each certified by the Secretary of State), and a copy of the Certificate of Incorporation must be filed with the office of the recorder of mortgages of the parish where the corporation’s registered office is located.
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