North Dakota Application to Obtain Certificate of Good Standing

Application to Obtain Certificate of Good Standing
Application To Obtain Certificate of Good Standing
APPLICATION TO OBTAIN CERTIFICATE
OF GOOD STANDING
NORTH DAKOTA OFFICE OF STATE TAX COMMISSIONER
SFN 60035 (Revised 10/11)

1. Taxpayer Legal Name

2. Federal Employer I.D. Number
(FEIN) or Social Security Number

3. Doing Business As Name (if different from line 1)

4. Business Telephone Number

6. Organization Type

State

City

5. Mailing Address

Sole Proprietorship
Partnership

General Partnership
Government

LLC
Association

ZIP Code

Corporation

Check the appropriate box(es):
Authorization To Disclose Tax Clearance Information. The Tax Commissioner is authorized to disclose
confidential tax information on file with the Office of State Tax Commissioner to the below-designated individual or
firm with respect to tax clearance.
Designated Individual (or Firm)
Telephone Number

Name of Individual (or Firm)
Street Address

City

Fax Number
State

ZIP Code

Email Address

Authorization To Disclose Tax Information Using Facsimile or Email. The Tax Commissioner is authorized to
use facsimile or email, or both, to disclose confidential tax information on file with the Office of State Tax
Commissioner to the above-designated individual or firm with respect to the above-identified matters.
Authorized Signature. I declare under the penalties of North Dakota Century Code ch. 12.1-11-02, which provides for a Class A
misdemeanor for making a false statement in a governmental matter, that this application, including any accompanying schedules and
statements, has been examined by me and to the best of my knowledge and belief is a true, correct and complete application.
Print Name of Authorized Individual

Title

Telephone Number

Signature

Date

Privacy Act information. In compliance with the Federal Privacy Act of 1974 (Public Law 93-579), the disclosure of an individual’s
social security number on the North Dakota income tax return and any required schedules is mandatory and is required under
subsections 1 and 7 of North Dakota Century Code §57-38-31. An individual’s social security number is used as an identification
number by the North Dakota Office of State Tax Commissioner for file control and recordkeeping purposes, and for cross-checking an
individual’s files with those of the Internal Revenue Service.

Mail to:

Office of State Tax Commissioner
Business Registration
600 E. Boulevard Ave., Dept. 127
Bismarck, ND 58505-0599

Contact:

Fax: 701-328-0332
Phone: 701-328-1241
Website: tax.nd.gov
Email: [email protected]