North Carolina Critical Infrastructure Company Notification

Critical Infrastructure Company Notification
Form NC-CICN
NC-CICN

Critical Infrastructure Company Notification

Web-Fill
10-19
Legal Name

Disaster
Response
Period

Trade Name

Beginning
(MM-DD-YY)

DOR Use Only
Mailing Address

City

State

Name of Contact Person

Zip Code

Phone Number

4

✖

PRINT

CLEAR

Ending

(MM-DD-YY)

FEIN or SSN

Date of Disaster Declaration

Fax Number
(MM-DD-YY)

Schedule A. Nonresident Business Information (If additional lines are needed, attach Schedule NBI available from the Department’s website.)
Legal Name

Taxpayer
Identification
Number

Principal Address
(Street Address, City, State, and Zip-Code)

Date of Entry
into NC
(MM-DD-YY)

Date of Exit
from NC
(MM-DD-YY)

A critical infrastructure company must provide notification to the Department of Revenue within 90 days of the expiration of the disaster response period.
Mail this notification to: North Carolina Department of Revenue, Attn: Business Liaison - Examination Division, PO Box 871, Raleigh, North Carolina 27602-0871.

Page 2, NC-CICN, Web-Fill, 10-19

Legal Name

FEIN/SSN

Schedule B. Nonresident Employee Information (If additional lines are needed, attach Schedule NEI available from the Department’s website.)
Name
(Last, First, and Middle Initial)

Social Security
Number

Principal Address
(Street Address, City, State, and Zip-Code)

Date of Entry
into NC
(MM-DD-YY)

Date of Exit
from NC
(MM-DD-YY)

Amount of Compensation Paid for Work
Performed in NC by Calendar Year
Compensation
Calendar Year
(YYYY)
Amount