Application For Merchants Registration Certificate And Exemption Certificate {AS 2914.1}

Form AS 2914.1 Rev. Aug 30 11 Commonwealth of Puerto Rico DEPARTMENT OF THE TREASURY Serial Number PART I - INFORMATION OF MERCHANT'S PRINCIPAL OFFICE 1. Legal name of the corporation, partnership, individual owner (name, initial, last name) or other APPLICATION FOR MERCHANT'S REGISTRATION CERTIFICATE Receipt Stamp 2. Social security or employer identification number under which the income from this activity will be informed on the income tax return (It is mandatory to complete this line) 3. Telephone Ext. 4. E-mail address 5. Postal address (Post Office Box, Urbanization or Building, Number or Apartment, Street) Municipality / City State Zip Code Country 6. Principal office's physical address (Urbanization or Building, Number or Apartment, Street) Municipality / City State Zip Code Country 7. Type of organization: Individual Estate or Trust Month Year Corporation or Partnership 9. Closing date of your accounting period: Day Month 8. Date of incorporation or creation: Day $ 10. Aggregate business volume, estimated or projected, at the end of the current calendar year (It shall be the sum of the business volume of all your locations): , , . 11. Amount of locations / activities included in this application: 12. Amount of Schedules included with this application: (It cannot be less than one) PART II - LOCATIONS / ACTIVITIES Indicate the information for each one of the locations operated by the business (submit Schedule AS 2914.1 if necessary). - * - You shall complete all lines of this part in order to process the application. - * 13. Trade name or "DBA" 14. Type of registration certificate requested (Check one): If you checked Temporary Business or Exhibitor, indicate:(From: Day 15. Telephone 17. Description of tangible personal property 18. Physical address (Urbanization or Building, Number or Apartment, Street). If it is the same as the one indicated on line 6, check here and continue on line 19 . Merchant Month Mobile business Year Temporary business To: Day Month Exhibitor Year Yes No ) Ext. 16. Will you sell tangible personal property? Municipality / City State Zip Code Country Retention: Six (6) years. American LegalNet, Inc. www.FormsWorkFlow.com Form AS 2914.1 Rev. Aug 30 11 Page 2 CONTINUED PART II (LOCATIONS / ACTIVITIES) 19. Description of the activity 21. Beginning date of operations: 20. North American Industry Day Month Year Classification System (NAICS) 22. Indicate if you are a: Reseller Manufacturing Plant (If you are interested in requesting an Exemption Certificate, refer to Form AS 2914.1 D) , , . PART III - PERSONS HAVING INTEREST IN THE BUSINESS 24. Indicate the information for each owner, partner, shareholder or any other person owning 50% or more interest in the business: 24a. Name Title If your business provides services, do you own 50% or more interest in another business? Name 24b. Name Title If your business pvovides services, do you own 50% or more interest in another business? Name Yes Yes Ownership percentage Social security or employer identification number No. If "Yes", indicate the following information for the other business: Social security or employer identification number Ownership percentage Social security or employer identification number No. If "Yes", indicate the following information for the other business: Social security or employer identification number 23. Business volume, estimated or projected, at the end of the current calendar year: $ NOTIFICATION REGARDING THE IVU LOTO OVERSIGTH PROGRAM Once you receive your Merchant's Registration Certificate, you are required to register for purposes of the IVU Loto oversight program through the www.ivuloto.pr.gov website or by calling (787) 200-7900 Option Number 4. (It does not apply to merchants registered as temporary businesses or exhibitors). For additional details, refer to the instructions of this form. OATH I hereby declare under penalties of perjury that this application has been examined by me, and that to the best of my knowledge and belief, all the information provided herein is true, correct and complete. I also agree to notify the Secretary of the Treasury of any change in the information provided on this application, within 30 days of the change or event. The declaration of the person that prepares this application (except the merchant) is with respect to the available information, and such information has been verified. Merchant's name Title Name of duly authorized agent Social security or employer identification number Merchant's signature Date Signature of duly authorized agent Address Date Telephone TO BE COMPLETED BY THE DEPARTMENT OF THE TREASURY Employee's name District Retention: Six (6) years. After evaluating this application, I certify that it is complete in all of its parts and that the information provided herein is presumed to be true. Nevertheless, the Department of the Treasury reserves the right to conduct any future investigation to verify the information. Employee's signature Date Confirmation number American LegalNet, Inc. www.FormsWorkFlow.com Schedule AS 2914.1 Rev. Aug 30 11 LOCATIONS Legal name of the corporation, partnership, individual owner (name, initial, last name) or other Use this Schedule if you own more locations than the spaces provided in Part II of the Application for Merchant's Registration Certificate and Exemption Certificate (Form AS 2914.1). 1. Trade name or "DBA" 2. Type of registration certificate requested (Check one): If you checked Temporary Business or Exhibitor, indicate: (From:Day 3. Telephone 5. Description of tangible personal property 6. Physical address (Urbanization or Building, Number or Apartment, Street) Ext. Merchant Month Mobile business Year Temporary business To:Day Month Exhibitor Year Yes No ) 4. Will you sell tangible personal property? Municipality / City State Zip Code Country 7. Description of the activity 8. North American Industry 9. Beginning date of operations: Classification System (NAICS) Day Month Year 10. Indicate if you are a: Reseller Manufacturing Plant (If you are interested in requesting an Exemption Certificate, refer to Form AS 2914.1 D) , , . 11. Business volume, estimated or projected, at the end of the current calendar year: $ 1. Trade name or "DBA" 2. Type of registration certificate requested (Check one): If you checked Temporary Business or Exhibitor, indicate: (From:Day 3. Telephone 5. Description of tangible personal property 6. Physical address (Urbanization or Building, Number or Apar