FR500 FR 500 042214

User Manual: FR500

Open the PDF directly: View PDF PDF.
Page Count: 16

GOVERNMENT OF THE DISTRICT OF COLUMBIA
OFFICE OF THE CHIEF FINANCIAL OFFICER
OFFICE OF TAX AND REVENUE
• List of Principal Business Activity Codes (NAICS)
• Instructions
• Form FR-500
• General Information (Part I)
• Franchise Tax Registration (Part II)
• Employer’s DC Withholding Tax Registration (Part III)
• Sales and Use Tax Registration (Part IV)
• Personal Property Tax Registration (Part V, Section 1)
• Ballpark Fee Registration (Part V, Section 2)
• Nursing Facility Registration (Part V, Section 3)
• Tobacco Products Excise Tax Registration (Part V, Section 4)
• Intermediate Care Facility for Persons with Intellectual or Developmental Disabilities (ICF-IDD)
Tax Registration (Part V, Section 5)
• Hospital Revenue Assessment (Part V, Section 6)
Hospital Provider Fee (Part V, Section 7)
• Miscellaneous Tax (Part V, Section 8)
• Unemployment Compensation Tax Registration (Part VI)
NOTE:
Effective immediately, demographic information (Part 1, Line 13) is MANDATORY.
Failure to complete this form in full may result in your denial for an application for a license or permit with
other DC Government agencies.
Corporations must provide Articles of Incorporation or Articles of Organization with the completed FR-500.
Trade names must be first registered with the Department of Consumer and Regulatory Affairs (DCRA).
FR-500
OFFICE OF TAX AND REVENUE (OTR)
CUSTOMER SERVICE ADMINISTRATION
1101 4TH STREET, SW
Washington DC 20024
Telephone No. (202) 727-4TAX (4829)
(Rev. 03/14)
COMBINED REGISTRATION APPLICATION FOR BUSINESS DC TAXES/FEES/ASSESSMENTS
Agriculture, Forestry, Fishing
and Hunting
Code
Crop Production
111100 Oilseed & Grain Farming
111210 Vegetable & Melon Farming
(including potatoes & yams)
111300 Fruit & Tree Nut Farming
111400 Greenhouse Nursery, &
Floriculture Production
111900 Other Crop Farming (including
tobacco, cotton, sugarcane, hay,
peanut, sugar beet & all other
crop farming)
Animal Production
112111 Beef Cattle Ranching &
Farming
112112 Cattle Feedlots
112120 Dairy Cattle & Milk Production
112210 Hog & Pig Farming
112300 Poultry & Egg Production
112400 Sheep & Goat Farming
112510 Animal Aquaculture (including
shellfish & finfish farms &
hatcheries)
112900 Other Animal Production
Forestry and Logging
113110 Timber Tract Operations
113210 Forest Nurseries & Gathering
of Forest Products
113310 Logging
Fishing, Hunting and Trapping
114110 Fishing
114210 Hunting & Trapping
Support Activities for Agriculture and
Forestry
115110 Support Activities for Crop
Production (including cotton
ginning, soil preparation,
planting & cultivating)
115210 Support Activities for Animal
Production
115310 Support Activities for Forestry
Mining
211110 Oil & Gas Extraction
212110 Coal Mining
212200 Metal Ore Mining
212310 Stone Mining & Quarrying
212320 Sand, Gravel, Clay, & Ceramic
& Refractory Minerals Mining
& Quarrying
212390 Other Nonmetallic Mineral
Mining & Quarrying
213110 Support Activities for Mining
Utilities
221100 Electric Power Generation,
Transmission & Distribution
221210 Natural Gas Distribution
221300 Water, Sewage & Other
Systems
Construction
Building, Developing, and General
Contracting
233110 Land Subdivision & Land
Development
Code
233200 Residential Building
Construction
233300 Nonresidential Building
Construction
Heavy Construction
234100 Highway, Street, Bridge, &
Tunnel Construction
234900 Other Heavy Construction
Special Trade Contractors
235110 Plumbing, Heating, &
Air-Conditioning Contractors
235210 Painting & Wall Covering
Contractors
235310 Electrical Contractors
235400 Masonry, Drywall, Insulation, &
Tile Contractors
235500 Carpentry & Floor Contractors
235610 Roofing, Siding, & Sheet Metal
Contractors
235710 Concrete Contractors
235810 Water Well Drilling Contractors
235900 Other Special Trade Contractors
Manufacturing
Food Manufacturing
311110 Animal Food Mfg
311200 Grain & Oilseed Milling
311300 Sugar & Confectionery Product
Mfg
311400 Fruit & Vegetable Preserving &
Specialty Food Mfg
311500 Dairy Product Mfg
311610 Animal Slaughtering and
Processing
311710 Seafood Product Preparation &
Packaging
311800 Bakeries & Tortilla Mfg
311900 Other Food Mfg (including
coffee, tea, flavorings &
seasonings)
Beverage and Tobacco Product
Manufacturing
312110 Soft Drink & Ice Mfg
312120 Breweries
312130 Wineries
312140 Distilleries
312200 Tobacco Manufacturing
Textile Mills and Textile Product Mills
313000 Textile Mills
314000 Textile Product Mills
Apparel Manufacturing
315100 Apparel Knitting Mills
315210 Cut & Sew Apparel Contractors
315220 Men’s & Boys’ Cut & Sew
Apparel Mfg
315230 Women’s & Girls’ Cut & Sew
Apparel Mfg
315290 Other Cut & Sew Apparel mfg
315990 Apparel Accessories & Other
Apparel Mfg
Leather and Allied Product
Manufacturing
316110 Leather & Hide Tanning &
Finishing
316210 Footwear Mfg (including rubber
& plastics)
316990 Other Leather & Allied Product
Mfg
Code
Wood Product Manufacturing
321110 Sawmills & Wood Preservation
321210 Veneer, Plywood, &
Engineered Wood Product Mfg
321900 Other Wood Product Mfg
Paper Manufacturing
322100 Pulp, Paper & Paperboard Mills
322200 Converted Paper Product Mfg
Printing and Related Support
Activities
323100 Printing & Related Support
Activities
Petroleum and Coal Products
Manufacturing
324100 Petroleum Refineries
(including integrated)
324120 Asphalt Paving, Roofing, &
Saturated Materials Mfg
324190 Other Petroleum & Coal
Products Mfg
Chemical Manufacturing
325100 Basic Chemical Mfg
325200 Resin, Synthetic Rubber &
Artificial & Synthetic Fibers &
Filaments Mfg
325300 Pesticide, Fertilizer, & Other
Agricultural Chemical Mfg
325410 Pharmaceutical & Medicine Mfg
325500 Paint Coating, & Adhesive Mfg
325600 Soap, Cleaning Compound, &
Toilet Preparation Mfg
325900 Other Chemical Product &
Preparation Mfg
Plastics and Rubber Products
Manufacturing
326100 Plastics Product Mfg
326200 Rubber Product Mfg
Nonmetallic Mineral Product
Manufacturing
327100 Clay Product & Refractory Mfg
327210 Glass & Glass Product Mfg
327300 Cement & Concrete Product
Mfg
327400 Lime & Gypsum Product Mfg
327900 Other Nonmetallic Mineral
Product Mfg
Primary Metal Manufacturing
331110 Iron & Steel Mills & Ferroalloy
Mfg
331200 Steel Product Mfg from
Purchased Steel
331310 Alumina & Aluminum Production
& Processing
331400 Nonferrous Metal (except
Aluminum) Production &
Processing
331500 Foundries
Fabricated Metal Product
Manufacturing
332110 Forging & Stamping
332210 Cutlery & Handtool Mfg
332300 Architectural & Structural Metals
Mfg
332400 Boiler, Tank, & Shipping
Container Mfg
332510 Hardware Mfg
332610 Spring & Wire Product Mfg
332700 Machine Shops; Turned
Product; & Screw, Nut, & Bolt
Mfg
332810 Coating, Engraving, Heat
Treating, & Allied Activities
332900 Other Fabricated Metal Product
Mfg
Machinery Manufacturing
333100 Agriculture, Construction, &
Mining Machinery Mfg
333200 Industrial Machinery Mfg
333310 Commercial & Service Industry
Machinery Mfg
333410 Ventilation, Heating, Air-
Conditioning, & Commercial
Refrigeration Equipment Mfg
333510 Metalworking Machinery Mfg
333610 Engine, Turbine & Power
Transmission Equipment Mfg
Code
333900 Other General Purpose
Machinery Mfg
Computer and Electronic Product
Manufacturing
334110 Computer & Peripheral
Equipment Mfg
334200 Communications Equipment
Mfg
334310 Audio & Video Equipment Mfg
334410 Semiconductor & Other
Electronic Component Mfg
334500 Navigational, Measuring,
Electromedical, & Control
Instruments Mfg
334610 Manufacturing & Reproducing
Magnetic & Optical Media
Electrical Equipment, Appliance, and
Component Manufacturing
335100 Electric Lighting Equipment Mfg
335200 Household Appliance Mfg
335310 Electrical Equipment Mfg
335900 Other Electrical Equipment &
Component Mfg
Transportation Equipment
Manufacturing
336100 Motor Vehicle Mfg
336210 Motor Vehicle Body & Trailer
Mfg
336300 Motor Vehicle Parts Mfg
336410 Aerospace Product & Parts Mfg
336510 Railroad Rolling Stock Mfg
336610 Ship & Boat Building
336990 Other Transportation Equipment
Mfg
Furniture and Related Product
Manufacturing
337000 Furniture & Related Product
Manufacturing
Miscellaneous Manufacturing
339110 Medical Equipment & Supplies
Mfg
339900 Other Miscellaneous
Manufacturing
Wholesale Trade
Wholesale Trade, Durable Goods
421100 Motor Vehicle & Motor Vehicle
Parts & Supplies Wholesalers
421200 Furniture & Home Furnishing
Wholesalers
421300 Lumber & Other Construction
Materials Wholesalers
421400 Professional & Commercial
Equipment & Supplies
Wholesalers
421500 Metal & Mineral (except
Petroleum) Wholesalers
421600 Electrical Goods Wholesalers
421700 Hardware, & Plumbing
& Heating Equipment &
Supplies Wholesalers
421800 Machinery, Equipment, &
Supplies Wholesalers
421910 Sporting & Recreational Goods
& Supplies Wholesalers
421920 Toy & Hobby Goods & Supplies
Wholesalers
421930 Recyclable Material
Wholesalers
421940 Jewelry, Watch, Precious Stone,
& Precious Metal Wholesalers
421990 Other Miscellaneous Durable
Goods Wholesalers
422100 Paper & Paper Product
Wholesalers
422210 Drugs & Druggists’ Sundries
Wholesalers
422300 Apparel, Piece Goods, &
Notions Wholesalers
422400 Grocery & Related Product
Wholesalers
422500 Farm Products Raw Material
Wholesalers
422600 Chemical & Allied Products
Wholesalers
Codes for Principal Business Activity
This list of principal business activities and their associated codes is
designed to classify an enterprise by the type of activity in which it is
engaged. These principal business activity codes are based on the North
American Industry Classification System.
If a company purchases raw materials and supplies them to a subcontrac-
tor to produce the finished product, but retains title to the product, the com-
pany is considered a manufacturer and must use one of the manufacturing
codes (311110-339900).
1
Code
Wholesale Trade, Durable Goods
422700 Petroleum & Petroleum
Products Wholesalers
422800 Beer, Wine, & Distilled Alcoholic
Beverage Wholesalers
422910 Farm Supplies Wholesalers
422920 Books, Periodical, & Newspaper
Wholesalers
422930 Flower, Nursery Stock &
Florists’ Supplies Wholesalers
422940 Tobacco & Tobacco Product
Wholesalers
422950 Paint, Varnish, & Supplies
Wholesalers
422990 Other Miscellaneous
Nondurable Goods Wholesalers
Retail Trade
Motor Vehicle and Parts Dealers
441110 New Car Dealers
441120 Used Car Dealers
441210 Recreational Vehicle Dealers
441221 Motorcycle Dealers
441222 Boat Dealers
441229 All Other Motor Vehicle Dealers
441300 Automotive Parts, Accessories,
& Tire Stores
Furniture and Home Furnishings
Stores
442110 Furniture Stores
442210 Floor Covering Stores
442291 Window Treatment Stores
442299 All Other Home Furnishings
Stores
Electronics and Appliance Stores
443111 Household Appliance Stores
443112 Radio, Television, & Other
Electronics Stores
443120 Computer & Software Stores
443130 Camera & Photographic
Supplies Stores
Building Material and Garden
Equipment and Supplies Dealers
444110 Home Centers
444120 Paint & Wallpaper Stores
444130 Hardware Stores
444190 Other Building Material Dealers
444200 Lawn & Garden Equipment &
Supplies Stores
Food and Beverage Stores
445110 Supermarkets and Other
Grocery (except Convenience)
Stores
445120 Convenience Stores
445210 Meat Markets
445220 Fish & Seafood Markets
445230 Fruit & Vegetable Markets
445291 Baked Goods Stores
445292 Confectionery & Nut Stores
445299 All Other Specialty Food Stores
445310 Beer, Wine, & Liquor Stores
Health and Personal Care Stores
446110 Pharmacies & Drug Stores
446120 Cosmetics, Beauty Supplies,
& Perfume Stores
446130 Optical Goods Stores
446190 Other Health & Personal Care
Stores
Gasoline Stations
447100 Gasoline Stations (including
convenience stores with gas)
Clothing and Clothing Accessories
Stores
448110 Men’s Clothing Stores
448120 Women’s Clothing Stores
448130 Children’s & Infants’ Clothing
Stores
448140 Family Clothing Stores
448150 Clothing Accessories Stores
448190 Other Clothing Stores
448219 Shoe Stores
448310 Jewelry Stores
448320 Luggage & Leather Goods
Stores
Code
Sporting Goods, Hobby, Book, and
Music Stores
451110 Sporting Goods Stores
451120 Hobby, Toy, & Game Stores
451130 Sewing, Needlework, & Piece
Goods Stores
451140 Musical Instrument & Supplies
Stores
451211 Book Stores
451212 News Dealers & Newsstands
451220 Prerecorded Tape, Compact
Disc, & Record Stores
General Merchandise Stores
452110 Department Stores
452900 Other General Merchandise
Stores
Miscellaneous Store Retailers
453110 Florists
453210 Office Supplies & Stationery
Stores
453220 Gift, Novelty, & Souvenir Stores
453310 Used Merchandise Stores
453910 Pet & Pet Supplies Stores
453920 Art Dealers
453930 Manufactured (Mobile) Home
Dealers
453990 All Other Miscellaneous Store
Retailers (including tobacco,
candle, & trophy shops)
Nonstore Retailers
454110 Electronic Shopping & Mail-
Order Houses
454210 Vending Machine Operators
454311 Heating Oil Dealers
454312 Liquefied Petroleum Gas
(Bottled Gas) Dealers
454319 Other Fuel Dealers
454390 Other Direct Selling
Establishments (including door-
to-door retailing, frozen food
plan providers, party plan
merchandisers, & coffee-break
service providers)
Transportation and Warehousing
Air, Rail, and Water Transportation
481000 Air Transportation
482110 Rail Transportation
483000 Water Transportation
Truck Transportation
484110 General Freight Trucking, Local
484120 General Freight Trucking, Long-
distance
484200 Specialized Freight Trucking
Transit and Ground Passenger
Transportation
485110 Urban Transit Systems
485210 Interurban & Rural Bus
Transportation
485310 Taxi Service
485320 Limousine Service
485410 School & Employee Bus
Transportation
485510 Charter Bus Industry
485990 Other Transit & Ground
Passenger Transportation
Pipeline Transportation
486000 Pipeline Transportation
Scenic & Sightseeing Transportation
487000 Scenic & Sightseeing
Transportation
Support Activities for Transportation
488100 Support Activities for Air
Transportation
488210 Support Activities for Rail
Transportation
488300 Support Activities for Water
Transportation
488410 Motor Vehicle Towing
488490 Other Support Activities for
Road Transportation
488510 Freight Transportation
Arrangement
Code
488990 Other Support Activities for
Transportation
Couriers and Messengers
492110 Couriers
492210 Local Messengers & Local
Delivery
Warehousing And Storage
493100 Warehousing & Storage (except
lessors of miniwarehouses &
self-storage units)
Information
Publishing Industries
511110 Newspaper Publishers
511120 Periodical Publishers
511130 Book Publishers
511140 Database & Directory
Publishers
511190 Other Publishers
511210 Software Publishers
Motion Picture and Sound Recording
Industries
512100 Motion Picture & Video
Industries (except video rental)
512200 Sound Recording Industries
Broadcasting and
Telecommunications
513100 Radio & Television Broadcasting
513200 Cable Networks & Program
Distribution
513300 Telecommunications (including
paging, cellular, satellite, & other
telecommunications)
Information Services and Data
Processing Services
514100 Information Services (including
news syndicates, libraries, &
on-line information services)
514210 Data Processing Services
Finance and Insurance
Depository Credit Intermediation
522110 Commercial Banking
522120 Savings Institutions
522130 Credit Unions
522190 Other Depository Credit
Intermediation
Nondepository Credit Intermediation
522210 Credit Card Issuing
522220 Sales Financing
522291 Consumer Lending
522292 Real Estate Credit (including
mortgage bankers & originators)
522293 International Trade Financing
522294 Secondary Market Financing
522298 All Other Nondepository Credit
Intermediation
Activities Related to Credit
Intermediation
522300 Activities Related to Credit
Intermediation (including loan
brokers)
Securities, Commodity Contracts, and
Other Financial Investments and
Related Activities
523110 Investment Banking & Securities
Dealing
523120 Securities Brokerage
523130 Commodity Contracts Dealing
523140 Commodity Contracts
Brokerage
523210 Securities & Commodity
Exchanges
523900 Other Financial Investment
Activities (including portfolio
management & investment
advice)
Code
Insurance Carriers and Related
Activities
524140 Direct Life, Health, & Medical
Insurance & Reinsurance
Carriers
524150 Direct Insurance & Reinsurance
(except Life, Health & Medical)
Carriers
524210 Insurance Agencies &
Brokerages
524290 Other Insurance Related
Activities
Funds, Trusts, and Other Financial
Vehicles
525100 Insurance & Employee Benefit
Funds
525910 Open-end Investment Funds
525920 Trusts, Estates, & Agency
Accounts
525930 Real Estate Investment Trusts
525990 Other Financial
Vehicles
“Offices of Bank Holding Companies”
and “Offices of Other Holding
Companies, are located under
Management of Companies (Holding
Companies)
Real Estate and Rental and
Leasing
Real Estate
531110 Lessors of Residential Buildings
& Dwellings
531114 Cooperative Housing
531120 Lessors of Miniwarehouses &
Self-Storage Units
531190 Lessors of Other Real Estate
Property
531210 Offices of Real Estate Agents &
Brokers
531310 Real Estate Property Managers
531320 Offices of Real Estate
Appraisers
531390 Other Activities Related to Real
Estate
Rental and Leasing Services
532100 Automotive Equipment Rental &
Leasing
532210 Consumer Electronics &
Appliances Rental
532220 Formal Wear & Costume Rental
532230 Video Tape & Disc Rental
532290 Other Consumer Goods Rental
532310 General Rental Centers
532400 Commercial & Industrial
Machinery & Equipment Rental
& Leasing
Lessors of Nonfinancial Intangible
Assets (except copyrighted works)
533110 Lessors of Nonfinancial
Intangible Assets (except
copyrighted works)
Professional, Scientific, and
Technical Services
Legal Services
541110 Offices of Lawyers
541190 Other Legal Services
Accounting, Tax Preparation,
Bookkeeping, and Payroll Services
541211 Offices of Certified Public
Accountants
541213 Tax Preparation Services
541214 Payroll Services
541219 Other Accounting Services
Architectural, Engineering, and
Related Services
541310 Architectural Services
541320 Landscape Architecture
Services
541330 Engineering Services
541340 Drafting Services
2
Code
Architectural Engineering, and
Related Services
541350 Building Inspection Services
541360 Geophysical Surveying &
Mapping Services
541370 Surveying & Mapping (except
Geophysical) Services
541380 Testing Laboratories
Specialized Design Services
541400 Specialized Design Services
(including interior, industrial,
graphic, & fashion design)
Computer Systems Design and
Related Services
541511 Custom Computer
Programming Services
541512 Computer Systems Design
Services
541513 Computer Facilities
Management Services
541519 Other Computer Related
Services
Other Professional, Scientific, and
Technical Services
541600 Management, Scientific, &
Technical Consulting Services
541700 Scientific Research &
Development Services
541800 Advertising & Related Services
541910 Marketing Research & Public
Opinion Polling
541920 Photographic Services
541930 Translation & Interpretation
Services
541940 Veterinary Services
541990 All Other Professional,
Scientific, & Technical Services
Management of Companies
(Holding Companies)
551111 Offices of Bank Holding
Companies
551112 Offices of Other Holding
Companies
Administrative and Support and
Waste Management and
Remediation Services
Administrative and Support Services
561110 Office Administrative Services
561210 Facilities Support Services
561300 Employment Services
561410 Document Preparation Services
561420 Telephone Call Centers
561430 Business Service Centers
(including private mail centers &
copy shops)
561440 Collection Agencies
561450 Credit Bureaus
561490 Other Business Support
Services (including reposses-
sion services, court reporting, &
stenotype services)
Code
561500 Travel Arrangement &
Reservation Services
561600 Investigation & Security
Services
561710 Exterminating & Pest Control
Services
561720 Janitorial Services
561730 Landscaping Services
561740 Carpet & Upholstery Cleaning
Services
561790 Other Services to Buildings &
Dwellings
561900 Other Support Services (includ-
ing packaging & labeling servic-
es, & convention & trade show
organizers)
Waste Management and Remediation
Services
562000 Waste Management &
Remediation Services
Educational Services
611000 Educational Services
(including schools, colleges, &
universities)
Health Care and Social
Assistance
Offices of Physicians and Dentists
621111 Offices of Physicians (except
mental health specialists)
621112 Offices of Physicians, mental
Health Specialists
621210 Office of Dentists
Offices of Other Health Practitioners
621310 Offices of Chiropractors
621320 Offices of Optometrists
621330 Offices of Mental Health
Practitioners (except
Physicians)
621340 Offices of Physical,
Occupational & Speech
Therapists, & Audiologists
621391 Offices of Podiatrists
621399 Offices of All Other
Miscellaneous Health
Practitioners
Outpatient Care Centers
621410 Family Planning Centers
621420 Outpatient Mental Health &
Substance Abuse Centers
621491 HMO Medical Centers
621492 Kidney Dialysis Centers
621493 Freestanding Ambulatory
Surgical & Emergency Centers
621498 All Other Outpatient Care
Centers
Medical and Diagnostic Laboratories
621510 Medical & Diagnostic
Laboratories
Home Health Care Services
621610 Home Health Care Services
Code
Other Ambulatory Health Care
Services
621900 Other Ambulatory Health Care
Services (including ambulance
services & blood & organ
banks)
Hospitals
622000 Hospitals
Nursing and Residential Care
Facilities
623000 Nursing & Residential Care
Facilities
Social Assistance
624100 Individual & Family Services
624200 Community Food & Housing, &
Emergency & Other Relief
Services
624310 Vocational Rehabilitation
Services
624410 Child Day Care Services
Arts, Entertainment, and
Recreation
Performing Arts, Spectator Sports,
and Related Industries
711100 Performing Arts Companies
711210 Spectator Sports (including
sports clubs & racetracks)
711300 Promoters of Performing Arts,
Sports, & Similar Events
711410 Agents & Managers for Artists,
Athletes, Entertainers & Other
Public Figures
711510 Independent Artists, Writers, &
Performers
Museums, Historical Sites, and
Similar Institutions
712100 Museums, Historical Sites &
Similar Institutions
Amusement, Gambling, and
Recreation Industries
713100 Amusement Parks & Arcades
713200 Gambling Industries
713900 Other Amusement & Recreation
Industries (including golf
courses, skiing facilities,
marinas, fitness centers, &
bowling centers)
Accommodations and Food
Services
Accommodations
721110 Hotels (except casino hotels)
& Motels
721120 Casino Hotels
721191 Bed & Breakfast Inns
721199 All Other Traveler
Accommodation
721210 RV (Recreational Vehicle) Parks
& Recreational Camps
721310 Rooming & Boarding Houses
Code
Food Services and Drinking Places
722110 Full-Service Restaurants
722210 Limited-Service Eating Places
722300 Special Food Services (includ-
ing food service contractors &
caterers)
722330 Mobile Food Vendors Including
Trucks and Hot Dog Carts
722410 Drinking Places (Alcoholic
Beverages)
Other Services
Repair and Maintenance
811110 Automotive Mechanical &
Electrical Repair & Maintenance
811120 Automotive Body, Paint, Interior,
& Glass Repair
811190 Other Automotive Repair
& Maintenance (including oil
change & lubrication shops &
car washes)
811210 Electronic & Precision
Equipment Repair &
Maintenance
811310 Commercial & Industrial
Machinery & Equipment (except
Automotive & Electronic) Repair
& Maintenance
811410 Home & Garden Equipment &
Appliance Repair &
Maintenance
811420 Reupholstery & Furniture
Repair
811430 Footwear & Leather Goods
Repair
811490 Other Personal & Household
Goods Repair & Maintenance
Personal and Laundry Services
812111 Barber Shops
812112 Beauty Salons
812113 Nail Salons
812190 Other Personal Care Services
(including diet & weight reduc-
ing centers)
812210 Funeral Homes & Funeral
Services
812220 Cemeteries & Crematories
812310 Coin-Operated Laundries &
Drycleaners
812320 Drycleaning & Laundry
Services (except Coin-
Operated)
812330 Linen & Uniform Supply
812910 Pet Care (except Veterinary)
Services
812920 Photofinishing
812930 Parking Lots & Garages
812990 All Other Personal Services
Religious, Grantmaking, Civic,
Professional, and Similar
Organizations
813000 Religious, Grantmaking, Civic,
Professional, & Similar
Organizations (including
condominium and homeowners
associations)
Additional codes can be found at
http://www.census.gov/eos/www/naics/
3
4
INSTRUCTIONS
The Combined Registration Application For Business DC
Taxes/Fees/Assessments (Form FR-500) is to be completed by
a business or consumer registering with the Government of the
District of Columbia (DC), Office of Tax and Revenue (OTR) and
the Department of Employment Services (DOES) for the follow-
ing taxes or payment:
• Corporation Franchise Tax Return (Form D-20)
• Unincorporated Business Franchise Tax Return (Form D-30)
• Employer Withholding Tax Return (Form FR-900 series)
• Sales and Use Tax Return (Form FR-800 series)
• Personal Property Tax Return (Form FP-31)
• Ballpark Fee
• Tobacco Products Excise Tax
• Department of Health Care Finance Assessments/Fees
(DHCF)
• Miscellaneous Tax
• Unemployment Compensation Tax (Registered by DOES)
GENERAL INSTRUCTIONS
The following general instructions will assist you in completing
Form FR-500.
Furnish all information requested in Parts I through VI. If
not applicable, write “N/A” in the answer block.
• Effective immediately, demographic information (Part I, Line
13) is mandatory.
Although there is some duplication of information requested
in Part I and Part VI, both parts must be completed. Part VI
is processed separately from Parts I through V-1 and V-2.
Answer all questions requesting a date with the month, day
and year.
Sign the application at the end of Parts V-7 and VI.
Return only the signed, original, completed application
form, DO NOT SEND COPIES.
PART I
Enter your Federal Employer Identification Number.
Enter your Social Security Number.
Enter the correct Business Activity Code from the list of
codes pro vided.
The identification number(s) entered on the Form FR-500 will
be used only for tax administration purposes.
PART II
DC TAX REQUIREMENTS
Corporation Franchise Tax
Unincorporated Business Franchise Tax
Corporation Franchise Tax — Every corporation engaging in or
carrying on a trade or business in DC and/or receiving income
from sources within DC must file a Corporation Franchise Tax
Return (Form D-20). The return must be filed by March 15th or
the 15th day of the third month following the close of the cor-
poration’s taxable year. If the amount of DC Gross Receipts
owed is less than the $250 minimum required payment, $250
must be paid.
Unincorporated Business Franchise Tax — An Unincorporated
Business Franchise Tax Return (Form D-30) is required of every
unincorporated business (sole proprietor, joint venture, etc.)
engaging in or carrying on a trade or business in DC, deriving
rental income, and/or receiving other income from sources
within DC, whose gross receipts exceed $12,000. A Form D-30
must be filed by April 15th or the 15th day of the fourth month
following the close of the business taxable year.
The minimum tax is $1,000 for corporate and unincorporated
filers with District gross receipts greater than $1 million.
5
Partnership Return of Income (D-65) — Partnerships not required to
file a Form D-30 (for whatever reason) must file a Form D-65.
Non-profi t Organizations — Organizations subject to tax on unrelated
business income, as defi ned in IRC §512, must fi le a Form D-20, Cor-
poration Franchise Tax return. The due date for this fi ling is the 15th
day of the fi fth month after the close of the organization’s tax year.
PART III
Employer Withholding Tax
Employer Withholding Tax — Every employer who pays wages to
a DC resident or payor of lump-sum distributions who withholds
DC income tax must fi le a DC withholding tax return. This includes
individual employers who have household employee(s). Lump-sum
distributions do not include:
(a) any portion of a lump-sum payment that was previously subject
to tax;
(b) an eligible rollover distribution that is effected as a direct trustee
to trustee transfer; and
(c) a rollover from an individual retirement account to a traditional or
Roth individual retirement account that is affected as a direct trustee
to trustee transfer.
An employer or payor who fails to withhold or pay withholding taxes
to DC is personally liable for the tax. If your withholding tax liability is
less than or equal to $200 per period, fi le an annual return, FR-900A.
The FR-900A is due on or before the 20th day of January following
the year being reported. If your withholding tax liability is greater than
or equal to $201 and less than or equal to $1200 per period, fi le a
quarter return, FR-900Q. The FR-900Q is due on or before the 20th
day of the month following the quarter being reported. If your with-
holding tax liability is greater than or equal to $1201 per period, fi le a
monthly return, FR-900M. The FR-900M is due on or before the 20th
day of the month following the month being reported.
The District requires withholding at the highest DC income tax rate
(8.95%) for DC residents on lump-sum distributions from retirement
accounts and plans.
Note: If your withholding tax liability is $5,000 or greater per
period, you shall fi le and pay electronically.
Visit www.taxpayerservicecenter.com
PART IV
Sales and Use Tax
Sales Tax — Every sales vendor, mobile food services vendor and
Business Benefi cial License Holder (BBLH) who has made any sale at
retail taxable under the provisions of District of Columbia (DC) Offi cial
Code §47-2001 et seq., shall fi le a return with the OTR. Such returns
shall show the total gross proceeds of the vendor's business for the
month, quarter or year for which the return is fi led; the gross receipts of
the business of the vendor upon which the tax is computed; the amount
of tax for which the vendor is liable and such other information that is
deemed necessary for the computation and collection of the tax. If your
sales and use liability is less than or equal to $200 per period, fi le an
annual return, FR-800A. The FR-800A is due on or before October
20th. If your sales and use tax liability is greater than or equal to $201
and less than or equal to $1200 per period, fi le a quarterly return,
FR-800Q. The FR-800Q is due on or before the 20th day of the month
following the quarter being reported. If your sales and use tax liability
is greater than or equal to $1201 per period, fi le a monthly return,
FR-800M. The FR-800M is due on or before the 20th day of the month
following the month being reported.
The promoter of a Special Event must provide a list of the par-
ticipants (the individuals who must collect DC sales tax from the
purchasers of any goods sold at the event). The list should contain
the name, address and telephone number of each participant, the
name and date(s) of the event. Please refer to the Special Event
Registration Application (Form FR-500B) for additional informa-
tion.
The Sales and Use Tax Special Event Return, Form FR-800SE, is
used to report and pay any sales and use tax liability arising from a
special event. It is due by the 20th of the month following the last
day of the special event.
A $.05 fee is imposed on each disposable carryout bag provided
by retail establishments - grocery stores, drug stores, liquor stores,
restaurants and food vendors (including street vendors) - to their
customers.
Street and Mobile Food Services Vendor Minimum Sales Tax (FR-800V)
Vendor Sales Tax Collection and Remittance Act of 2012 requires a
minimum sales tax that a street or mobile food services vendor (a
person licensed to vend from a sidewalk, roadway, or other public
space) must fi le and pay in lieu of the previous “payment in lieu of
collecting and remitting sales tax”. Street and mobile food services
vendors are required to collect sales tax and fi le and pay a street
vendor minimum sales tax (MST) quarterly tax return and remit the
greater of the taxes collected (5.75% or 10%) or the minimum sales
tax of $375 on a quarterly basis.
Use Tax — The use tax is imposed at the same rate as the
corresponding sales tax on the purchase or rental of tangible
personal property for the use, storage or consumption in DC by a
buyer who did not pay a sales tax to DC or any other tax jurisdiction
at the time of the purchase or rental of the property.
Employer Use Tax Return Act of 2012
Any employer required to fi le a DC withholding tax return, which is
not otherwise required to collect and remit sales tax, shall fi le an
annual use tax return on or before October 20th of each year, remit-
ting with such return the use taxes which are due.
Note: If your sales tax liability is $5,000 or greater, you shall fi le
and pay electronically. Visit www.taxpayerservicecenter.com
PART V, Section 1
Personal Property Tax
Personal Property Tax — A Personal Property Tax Return (Form
FP-31) must be filed by every business owning or holding in trust
any tangible personal property (furniture, computers, fixtures, books,
etc.) located in or having a taxable situs in DC. The tax applies to
property used or available for use in a trade, business or office held
for business purposes, including property kept in storage or held for
rent or which is leased to third parties, including governmental agen-
cies, under a “lease-purchase agreement.” A Form FP-31 must be
filed and the tax paid on or before July 31st of each year based upon
the remaining cost (current value) of all tangible personal property
owned as of July 1st.
Railroad companies operating rolling stock, parlor cars and sleeping
cars in DC over any railroad line, must file Form FP-32 (Railroad
Tangible Property Return) by July 31st of each year, on property
If you have any questions regarding these tax requirements, contact the Office of Tax and Revenue, Customer Service Administration,
1101 4th Street, SW, Washington, DC 20024; or call (202) 727-4TAX (4829). First time applicants must mail the original
application to: Office of Tax and Revenue, Customer Service Administration, PO Box 470, Washington, DC 20044-0470.
6
owned on July 1st. Also, every railroad company whose lines run
through DC, must report by July 31st of each year, on Form FP-33
(Railroad Company Report), and any other company whose cars run
on their DC tracks, must file Form FP-34 (Rolling Stock Tax Return)
together with full payment of the tax owed.
Note: If your personal property tax liability is $5,000 or greater, you
shall file and pay electronically.
Visit www.taxpayerservicecenter.com
PART V, Section 2
Ballpark Fee
Except as provided below, any person that derived at least $5 million
in annual District gross receipts and who was subject to any of the
following at any given point during that person’s most recent calen-
dar or fiscal year ending on or before June 15th, each year, shall file
and pay the Ballpark Fee online:
• DC Corporation Franchise Tax;
• DC Unincorporated Business Franchise Tax; or
• The DC Unemployment Compensation Act, except employers who
employ persons to provide personal or domestic services in a private
home unless the employment is in relation to the employer’s trade,
occupation, profession, enterprise or vocation.
PART V, Section 3
Nursing Facility Assessment
The nursing facility assessment liability is set annually on a fiscal
year basis, ending September 30th. Every nursing care provider
operating in the District must pay the nursing facility assessment.
Nursing care providers operated by the federal government are
exempt. The assessment can only be filed and paid online.
PART V, Section 4
Tobacco Products Excise Tax
Business must pay the tobacco products excise tax every quarter to
report ‘little cigars’ and other tobacco products sold in the District
during the reporting period using Form FR-1000Q.
PART V, Section 5
Intermediate Care Facility for Persons with Intellectual
or Developmental Disabilities (ICF-IDD)
Every ICF-IDD facility operating in the District must pay the ICF-IDD
assessment in quarterly installments. The assessment can only be
filed and paid online.
PART V, Section 6
Hospital Revenue Assessment
Annually, by September 1, each hospital operating in the District
must pay the assessment. The assessment can only be filed and paid
online.
PART V, Section 7
Hospital Provider Fee
Each hospital operating in the District must pay the hospital pro-
vider fee quarterly, due the 15th day of the District's fiscal year
quarter (Dec., Mar., June and Sept.) The fee can only be filed and
paid online.
7
Part V, Section 8
Miscellaneous Tax
Gross Receipts Tax — Utilities, telecommunication companies providing
long distance service, companies providing cable television, satellite
relay or distribution of video or radio transmission to subscribers and
paying customers, heating oil delivery companies, commercial mobile
service providers and non-public utility sellers of natural or artificial gas
are subject to a Gross Receipts Tax.
Companies subject to the Gross Receipts Tax must submit a monthly
report of their gross receipts from DC sources. Gross receipts are
reported by filing:
Form FP-27 for utilities;
Form FP-27T for toll telecommunication companies;
Form FP-27C for cable television, satellite relay, or distribution of
video and radio transmission companies;
Form FP-27NAG for non-public utility sellers of natural or artificial
gas;
Form FP-27M for commercial mobile service providers; or
Form FP-27H for heating oil delivery companies.
Companies must file the proper form by the 20th of the month following
the month being reported.
If you have any questions regarding these tax requirements, contact the Office of Tax and Revenue,
Customer Service Administration, 1101 4th Street, SW, Washington, DC 20024; or call (202) 727-4TAX (4829).
First time applicants must mail the original application to: Office of Tax and Revenue,
Customer Service Administration, PO Box 470, Washington, DC 20044-0470
8
Unemployment Compensation Tax — Employers who hire one or
more persons to perform services in DC must register for
Unemployment Compensation Taxes. Domestic/ house hold employ-
ers who pay cash remuneration of $500 or more in any calendar
quarter also must register and file reports. A non-profit organization
granted an exemption from the payment of FUTA taxes under
IRC §501(c)(3) may elect to reimburse the DC Office of
Unemployment Compensation instead of paying taxes.
ITEM 16 OF PART VI SHOULD ONLY BE COMPLETED BY NON-
PROFIT ORGANIZATIONS. If the organization is exempt from fed-
eral unemployment taxes, check the appropriate box and include a
copy of the Internal Revenue Service exemption letter.
A non-profit organization has two options for financing Unemployment
Insurance Coverage:
1. Paying contributions at the rate assigned by the DC Department
of Employment Services. The rate is applied to the taxable wages
earned by each employee during a calendar year. Contributions
are paid on a calendar quarter basis.
2. Reimburse the trust fund. At the end of each calendar quarter, the
employer is billed for unemployment benefits paid by DC to its
former employees during the quarter.
All items marked "REQUIRED" must be completed. Failure to com-
plete the required items will delay the processing of the registration.
PERCENTAGE OF ASSETS ACQUIRED. Enter the appropriate infor-
mation in Item 15 of Part VI of the form. List any prior DC ID num-
ber issued to you or to the business.
If you are a new employer acquiring your business from a predeces-
sor, answer the appropriate questions or state whether this is a
change in the entity doing business under individual ownership,
partnership or corporation. This information is necessary to deter-
mine your experience rate. If changing the trade name, include the
former trade name.
Questions concerning liability or financing options for
Unemployment Compensation Taxes should be directed to the DC
Department of Employment Services, Office of Unemployment
Compensation, Tax Division, 4058 Minnesota Ave., NE, 4th FL,
Washington, DC 20019 or telephone (202) 698-7550. The fac-
simile number is (202) 698-5706.
PART VI
UNEMPLOYMENT COMPENSATION TAX REGISTRATION
COMPLETE PART VI ONLY IF YOU HAVE EMPLOYEES WHO WORK IN THE DISTRICT OF COLUMBIA.
Although some information has already been requested in Part 1, this form must be completed in its entirely by all employers
who have employees working in the District of Columbia. PART VI will be processed separately from Parts I through V.
If you have any questions or need additional information regarding PART VI, please call the DC Department of
Employment Services Office of Unemployment Compensation-Tax Division at 202-698-7550
Please note that entities completing this form as a requirement for submitting contract proposals with the Government of the
District of Columbia MUST complete this form even if they do not have employees who work in the District of Columbia.
COMBINED REGISTRATION APPLICATION FOR
BUSINESS DC TAXES/FEES/ASSESSMENTS
GOVERNMENT OF THE DISTRICT OF COLUMBIA
OFFICE OF TAX AND REVENUE
PART I — General Information
1(a). Federal Employer Identification Number
■■
■■■■■■
■■■■■■
2. NAICS Business Code
■■■■■■
■■■■■■
1(b). Social Security Number
■■■
■■■
■■
■■■■
■■■■
3. Reason for application: (please check) 4. Legal form of business (please check):
New business Employment of household/domestic help Sole Proprietor Limited partnership
Additional location Address change Limited Liability Company Government
Purchased existing business Merger (attach merger agreement) General partnership Joint Venture
Name change Other (describe on an attachment) Limited Liability Partnership Other (specify)
(if a corporation, attach corporation amendment) Heating oil company Corporation
Legal form change Utility company
Street and Mobile Food Services Vendor
5. Business Name (Individual, Partnership, Corporation)
6. Trade Name (if different from Line 5)
7. Business Address (PO Box is not acceptable unless located in a Rural Area)
8. Mailing Address
9. Local Business Phone No. 10. Main Office Phone No. 10(a). Fax No. 11. Date present business began or is
expected to begin in DC
( ) ( ) ( ) Mo. ________ Day ________ Year ________
12. If previously registered with the DC, please provide:
Former Entity Name __________________________________________ Business Tax Registration Number ___________________________________
Former Trade Name ___________________________________________ Name of Former Owner(s) _________________________________________
13. NAME, TITLE, HOME ADDRESS, SOCIAL SECURITY NUMBER OF PROPRIETOR, PARTNERS OR PRINCIPAL OFFICERS
Name and Title Home Address Zip Code Social Security Number
Name and Title Home Address Zip Code Social Security Number
Name and Title Home Address Zip Code Social Security Number
PART II — Franchise Tax Registration
14. Indicate your profession, principal business activity or service (for example, retail grocery, wholesale auto parts, barber shop, doctor, contractor, etc.)
15. Do you or will you have an office, warehouse, or other place of business in DC, or a representative
with a DC location? Yes No
16. Do you or will you have merchandise stored in a public or private warehouse in DC? Yes No
17. Do you or will you perform in DC personal services (medical, accounting, consulting); or other services such as
electrical, heating, construction, etc., or installations or repairs of any type? Yes No
18. Do you or will you generate any business related income from DC sources? Yes No
19. Do you or will you have rental property in DC? Yes No 20. Date converted or expected to be converted to rental property ____/____/____
21. Date on which your taxable year ends: Month ________ Day ________ Year ________ (Calendar or Fiscal)
22. Describe fully ALL your current or expected business activities and/or major type of services performed within DC.
(Attach separate sheet if necessary.)
— INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED AND WILL BE RETURNED —
Mandatory: If incorporated, enter state and date of incorporation.
State _________________ Mo. _____ Day _____ Yr _____otherwise go to Line 5.
E-mail Address
E-mail Address
E-mail Address
(Rev. 03/14 )
FR-500
PART III — Employer’s DC Withholding Tax Registration
PART IV — Sales and Use Tax Registration
23. Estimated total number of employees __________ 24. Number of DC resident employees subject to DC
Withholding Tax: _______________
25a. Date when you began to employ DC resident(s) ____-____-____ 26. Estimate of amount of DC tax to be withheld monthly from
mo. day yr. DC resident employees:
25b. Date when you began or when you expect to begin
to withhold DC tax from resident employees ____-____-____ 27. Will you have employee(s) working in DC?
28. Withholding from retirement accounts or plans
29. Check applicable box(es) below
Reporting Sales Tax on retail sales or rentals.
Reporting Use Tax on items purchased tax free inside/outside DC
Purchasing in DC items for resale outside DC (Attach photocopy of state/county sales tax registration.)
Purchasing in DC cigarettes for resale outside DC (Attach photocopy of state/county cigarette/tobacco license.)
Making no taxable sales and tax is paid to vendors on all taxable purchases.
Making exempt sales where a Certificate of Resale is issued.
30. Date when sales/use began in DC (mo./day/yr.) ______/______/______ or date expected to begin.
31. If you have more than one place of business where you collect taxes on sales
in DC, do you wish to file a Combined Sales Tax Return for all locations? Yes No
Please attach a statement listing the additional places of business.
PART V, Section 1 — Personal Property Tax Registration
Describe the type of Personal Property at each location (ex. furniture, fixtures, machinery equipment and supplies), used for business purposes.
PART V, Section 2 — Ballpark Fee Registration
Are annual gross receipts greater than $5 million? Yes No
PART V, Section 3 — Nursing Facility/Registration
Yes No Begin date (MMDDYYYY) ____/____/________ End date (MMDDYYYY) ____/____/________
PART V, Section 4 — Tobacco Products Excise Tax Registration
Yes No Begin date (MMDDYYYY) ____/____/________ End date (MMDDYYYY) ____/____/________
PART V, Section 5 —
Intermediate Care Facility for Persons with Intellectual or Developmental Disabilities (ICF-IDD) Tax Registration
Yes No Begin date (MMDDYYYY) ____/____/________ End date (MMDDYYYY) ____/____/________
PART V, Section 6 — Hospital Revenue Assessment
Yes No Begin date (MMDDYYYY) ____/____/________ End date (MMDDYYYY) ____/____/________
PART V, Section 7 — Hospital Provider Fee
Yes No Begin date (MMDDYYYY) ____/____/________ End date (MMDDYYYY) ____/____/________
Begin date (MMDDYYYY) __ /___/____ End date (MMDDYYYY) ___/___/____
Street and Mobile Food Services Vendor.
Yes No
PART V, Section 8 — Miscellaneous Tax Registration
CERTIFICATION
I declare under penalties as provided by law that this application (including any accompanying schedules and statements) has been examined
by me and, to the best of my knowledge, it is correct.
etaDeltiTerutangiS
APPLICATIONS WHEN COMPLETED MUST BE SIGNED BY EITHER THE OWNER, PARTNER OR PRINCIPAL OFFICER
OF THE CORPORATION. (Agents or Representatives signing must attach a
Power of Attorney
.)
Check applicable block(s) below and the appropriate payment booklets/returns will be sent to you or available on the website.
Alcoholic Beverage Wholesaler Gross Receipts Tax on Heating Oil
Cable Television, Satellite Relay or Distribution of Video or Radio Transmission only Interstate Bus
Cigarette Wholesaler Motor Vehicle Fuel Tax
Commercial Mobile Service Tax Gross Receipts Tax on Natural or Artificial Gas by
nosreP ytilitU cilbuP-noNytilitU cilbuP stpieceR ssorG
Gross Receipts Tax on Toll Telecommunication Service
If you have questions please contact the Customer Service Administration at (202) 727-4TAX (4829).
OFFICIAL USE ONLY
Type Date Lia.
Tax began Cycle Method Remarks
H
J
W
S
P
MISC
Reviewer/Date
Date Data Entered/Initials
Medical Marijuana
PART VI — Unemployment Compensation Tax Registration
1. Federal Employer
Identification Number
3. Type of ownership
(check one)
Sole Proprietor Household/domestic
Partnership Limited Liability Company
Joint Venture Limited Liability Partnership
Corporation Other (specify)
___________________________
If incorporated, enter:
State __________________ Date ___________________
MM / DD / YYYY
4. Describe in detail your business activity and/or major source of sales that generate sales and use tax; specify the product manufactured
and/or sold, or the type of service performed. (Omission of this information may delay the determination of your status.)
5. Legal entity name 6. Trade name (if different from line 5)
7. Street address of DC business, worksite or employee’s home 8a. Mailing address for Tax Correspondence
Mailing address for Benefits Correspondence
address if working from home. Application will NOT be processed
without a DC address. (PO Box is not acceptable)
2. Previously assigned unemployment
insurance number
(if applicable)
Reason for applying:
New Business Additional location
Merger (attach merger Purchased existing
agreement) business
Household/domestic Other (specify)
Change of Entity ________________________
Reorganization
Name Change
(if a corporation attach corporation amendment)
Although some information has already been requested in Part 1, this form must be completed in its entirety by all employers who
have employees working in the District of Columbia. PART VI will be processed separately from Parts I through V.
If you have any questions or need additional information regarding PART VI, please call the DC Department of Employment
Services Office of Unemployment Compensation-Tax Division at 202-698-7550 for assistance or email doesregistration@dc.gov
— COMPLETE REVERSE SIDE —
8b.
COMPLETE PART VI TO DETERMINE UNEMPLOYMENT INSURANCE LIABILITY
Please note that entities completing this form as a requirement for submitting contract proposals with the Government of the District
of Columbia MUST complete this form even if they do not have employees who work in the District of Columbia.
12a. Date wages were first paid to employees performing services in DC
(write N/A if there were no services performed in DC.)
Month: Day: Year:
12b. For household employers only. Do you have an individual in your private DC
residence performing personal, rather than business, services to whom you
pay $500 or more in one calendar quarter? Yes No
If yes: indicate the earliest quarter and calendar year when you paid $500 or
more : Quarter: _______ Year: _______
Check your preference for filing Contribution and Wage Reports:
Quarterly _____ Annually ______
13. Number of workers employed in DC (including officers).
14. List all places of business in DC
EDOC PIZSSERDDA NOITACOLEMAN SSENISUB
15. If the reason for registering is due to the purchase of an existing business, merger, reorganization, or change of legal entity, or the
acquisition, assumption or transfer of the workplace of another entity or entities, provide the following information including the
percentage of assets and/or workforce acquired (if needed, attach an additional explanation of transactions).
Nature of transfer (check appropriate box):
Purchase Merger or consolidation Foreclosure Receivership
Lease Corporate Reorganization Bankruptcy Assignment
Partnership reorganization (admission or withdrawal of one or more partners).
Other (specify in detail): ____________________________________________________________________________________________
Percent of assets acquired: % Date of aquisition transfer: Month: Day: Year:
rebmuN
tnuoccA
srossecederPe (Legal Entity Name)maN
srossecederP
Address
Trade name (D/B/A) under which transferred business or business that formerly employed your acquired workforce was operated.
This space for official use only.
Account Number ______________________________
Date _________________________________________
Signature _____________________________________
11. List proprietor, partners, or principal officers ALL FIELDS MUST BE COMPLETED:
r (REQUIRED)ebmuN ytiruceS laicoSs (REQUIRED)serddAe (REQUIRED)ltiT dna emaN
9. Electronic Means of Communication (REQUIRED)
(Leave blank if not applicable)
Local Voice Number ______________________________
Local Fax Number ______________________________
Main Office Voice Number ______________________________
Main Office Fax Number ______________________________
Tax E-mail Address ______________________________
Website Address ______________________________
10. Owner, officer, or agent responsible for reporting and remitting
unemployment taxes:
Name __________________________________________________
Title ___________________________________________________
Voice No. ______________________________________________
Fax No. ________________________________________________
16. COMPLETE THIS PART ONLY IF THIS IS A NON-PROFIT ORGANIZATION
16a.Is the organization covered by the Federal Unemployment Tax Act? 16b.Is the organization exempt from Federal income taxes under
Yes No
Unemployment Tax Act? Yes No
Yes No (If yes, please attach a copy of the §501(c)(3) exemption letter.)
16c.Choose an option to finance unemployment insurance coverage
(see instructions)
Contributions Reimbursement of trust fund
CERTIFICATION.
I declare under penalties as provided by law that Part VI (including any accompanying schedules and statements) has been
examined by me and, to the best of my knowledge, it is correct.
rebmuN
enohpeleTetaDeltiTerutangiS
THE COMPLETED PART VI MUST BE SIGNED BY THE OWNER, PARTNER OR PRINCIPAL OFFICER OF THE
BUSINESS, OR BY AN AGENT (Power of Attorney must be attached if signed by an agent.)
Return completed forms to: Department of Employment Services
4058 Minnesota Ave. NE 4th FL
Office of Unemployment Compensation - Tax Division
Washington, DC 20019
or email to: doesregistration@dc.gov
Please note that wage information and other confidential unemployment compensation information may be requested and used for other
government purposes, including determination or verification of an individual eligibility for other government programs, This notice is required
by 20 CFR
§
603.11(b).
§501(c)(3) of the IRS code for religious, educational, or
charitable purposes?
IMPORTANT NOTICE
PLEASE NOTE THAT FAILURE TO COMPLETE ALL ITEMS MARKED “REQUIRED” OR
OTHERWISE INDICATED AS REQUIRED WILL EITHER DELAY THE PROCESSING OF
THE APPLICATION OR CAUSE THE INCOMPLETE APPLICATION TO BE RETURNED
FOR ADDITIONAL INFORMATION.
Print Name Email Address
If NO, is it exempt under
§3306(c)(8) of the Federal

Navigation menu