Revenue Form 2000 - state.nj.us

1 REPORTING FORMAI:'; (Please choose only 1 qfthefollowing 4 reporting methods) Lists or Printouts: This method can be used fbr reporting several newly hired employees at once. Maillists to our New Hire Operations Center or fax lists to 800-304-4901. using the following format:PAPERLIST or PRINTOUTS Federal Employer Identification Number (FEIN): 000112222 Employer Payroll 0\ddress: SSN First Ml Last Name Name xxx-xx-xxxx ROBERT C CLARKE xxx-xx-xxxx ANGELA R SMITH xxx-xx-xxxx DAVID J CARBO Address 34 PERKINS DR Ill MAIN ST 12 GREEN ST City Wigit International.

2 Inc. 75 Curbside Lane Somewhere, NJ 08601 State Zip Date of Hire (Opt) NEWBURN 08652 10/23/97 TRENTON NJ08603 10/06/97 READING NJ08127 10/03/97 Date of Birth Gender (If Available) (Optional) 08/06/59 M 12/03/57 F 04/26/66 M 2. New Hire Reporting Form: The attached form can be used to report individual employees and can be pho tocopied. Refer to it for instructions for completing the required information. Mail a copy to our Ne\\ I lireOperation Center or Fax it to 800-304-4901. To obtain copies or these forms visit our World Wide Web site Copy of a W-4 Form: Employers may also use W-4 forms to report.

3 After the employee completes his or herinformation (lines 1-7). add the employer's name, and address, (line 8) and FElN (line JOJ. To obtain copic orW-4 forms, call the Internal Revenue Service at (800) 829-3676, or visit the [RS's World Wide Web site athttp:/ ..4. Electronic Media: Call the NJ Operations Center at (toll-free) l-877-NJ-HIRES, for technical support forcer tification information. and mailing of electronic media to our New Hire Operations Center. Acceptable electronicmedia art: 3s diskettes, round magnetic tapes. and cartridges .. MULTI-STATE REPORTING BY EMPLOYERS Beginning October 1, 1997, an employer that has employees in two or more states and transmits reports electroni cally may report all new hires to one state if the employer does both of the following: ( I)Notifies the United states Secretary of Health & Human Services, in writing.)]

4 Of which state the employerhas designated to receive the report.(2)Transmits the report to that state in compliance with federal and state are a multi-state employer and you elect to send New Hire reports to New Jersey. you must first notif); the federal government of your request at the following address: Qf/EST! \/S Department of Health and Human Services Federal Ollice or Child Support Enforcement Multi-state Employer Registration Post Office Box 509 Randallstown, Maryland 21133 202-40] -9267 Please direct any questions regarding New Hire Rcp(l[Ling to the New Jersey Operations Cenler at or our e-mail address at or call customer service directly at (toll free).

5 ////////////////Under penalties of perjury, I declare that I have examined this election, including accompanying schedules and statements, and to the best of my knowledge and belief, it istrue, correct, and of authorized officerTitleDateSocial Security NumberorEmployer Identification Numberfor an estate or qualified trust* Share-holder sstate ofresidencyState of New JerseyDivision of TaxationNew Jersey S Corporation or New Jersey QSSS ElectionCheck the appropriate box: Initial S Corporation Election New Jersey QSSS Election (See Part V) Change in S or QSSS Corporation ShareholdersIMPORTANT: This form only has to be filed once.

6 There is no renewal Note: All changes can be filed with the S corporation final return. //////////Check here if the corporation has changed its name or address in the past 12 monthsFederal Employer Identification Number-New Jersey Corporation Number--Name and telephone number of corporate officer or legal representative() -Date of IncorporationState of Incorporation//Part ICorporate Information(Type or Print)Name of CorporationMailing AddressCity or Town, State and ZIP CodeCBT-2553(8-05)Election InformationEnter the effective date of the Federal S corporation election _____/_____/_____Applied for monthdayyearNew Jersey S corporation or New Jersey QSSS election is to be effective for tax year beginning _____/_____/_____ ending _____/_____/_____ monthdayyearmonthdayyearNOTE: If this election takes effect for the first tax year the corporation exists, enter for item 2 and item 3, the month, day and year of the earliest of the following.

7 (1) date the corporation first had shareholders, (2) date the corporation first had assets, or (3) date the corporation began doing the accounting period you enter is for an automatic 52-53 week tax year, check here Part IIShareholder s Consent Statement - By signing this election, we the undersigned shareholders, consent (1) to the corporation s election to betreated as a New Jersey S corporation under 54:10A-1, et seq., (2) that New Jersey shall have the right and jurisdiction to tax and collect thetax on each shareholder s S corporation income, as defined in 54A:5-10 and (3) such right and jurisdiction shall not be affected by a changeof a shareholder s residency, except as provided in 54A:1-1, et seq.

8 Shareholders must sign, date and provide the requested informationbelow. For the original or initial election to be valid, the consent of each shareholder, person having a community property interest in the corporation sstock, and each tenant in common, joint tenant, and tenant by the entirety must appear below or be attached to this form. If more space is needed, acontinuation sheet reporting the exact information for additional shareholders or a second consent statement must be attached to this of each shareholder, person having acommunity property interest in the corporation sstock, and each tenant in common, joint tenant, andtenant by the entirety.

9 (A husband and wife (andtheir estates) are counted as one shareholder).SignatureDateStock OwnedNumberofsharesDatesacquiredPart IIIC orporation s Consent Statement- The above named corporation consents (1) to the election to be treated as a New Jersey S corporation 54:10A-1, et seq., (2) to fulfill any tax obligations of any nonconsenting shareholder who was not an initial shareholder as required by any taxlaw in the State of New Jersey including the payment of tax to the State of New Jersey on behalf of such shareholder. (An authorized officer must signand date below.)

10 Part IVPersons who are no longer shareholders of the of shareholder, person no longer having a communityproperty interest in the corporation s stock, tenant in common,joint tenant, or tenant by the entirety. (A husband and wife(and their estates) are counted as one shareholder).DateStock RelinquishedSocial Security NumberorEmployer Identification Numberfor an estate or qualified trustDo not enter any shareholder who sold or transferred all of his or her stockbefore the election was penalties of perjury, I declare that the above, to the best of my knowledge and belief, is true, correct, and of authorized officerTitleDate* You must provide the address of any shareholder who is not a resident of New Jersey on a rider and attach it to this 41 -** Signatures mustbe provided **XUnder penalties of perjury.