North Dakota Request for Renaissance Zone Certificate of Good Standing or State Tax Clearance Record

Request for Renaissance Zone Certificate of Good Standing or State Tax Clearance Record
Request For Renaissance Zone Certificate of Good Standing Or State Tax Clearance Record
	
	
	
	

REQUEST FOR RENAISSANCE ZONE CERTIFICATE OF
GOOD STANDING OR STATE TAX CLEARANCE RECORD

OFFICE OF STATE TAX COMMISSIONER

ND Tax Department
Use Only

SFN 28220 (04-2020)




Part 1 - Type of request

Approved
Not approved

This is a request for a: (Check applicable box)
	
A.	 	 Renaissance zone certificate of good standing (N.D.C.C. §§ 40-63-11 and 57-01-15.1)
			Check this box if you need a certificate of good standing because you are applying for an income or property tax
exemption or income tax credit under the Renaissance Zone Program.
	
B.	 	 Non-renaissance zone property tax exemption state tax clearance record (N.D.C.C. § 57-01-15.1)
			
Check this box if applying for one of the following property tax exemptions. Also check the exemption being claimed.
				 New or expanding business property tax exemption under N.D.C.C. ch. 40-57.1.
				 Development or renewal area property tax exemption (tax increment financing) under N.D.C.C. ch. 40-58.

Part 2 - Taxpayer information
Legal Name of Taxpayer (If a sole proprietorship, enter name of individual who owns the business.)
Trade or Doing Business as Name, if Different from Legal Name Above
Current Mailing Address	

City	

State	

ZIP Code

Type of Entity	
6.	 	
Limited Liability Company (Filing as a Partnership)
	 1. 	 	Individual (or Sole Proprietorship)	
7.	 	
Limited Liability Company (Filing as an S Corporation)
	 2.	 	Regular (C) Corporation	
8.	 	
Limited Liability Company (Treated as a Disregarded Entity) - Identify Owner Below:
	 3.	 	
Partnership (all Types)			 Owner’s Name: ___________________________________________________
	 4.	 	
Subchapter S Corporation	
		 Owner’s Social Security Number or FEIN: _______________________________
	 5.	 	
Estate or Trust	
9.	 	Other (Identify) _____________________________________________
Important: Except for an individual (or sole proprietorship), all taxpayers must complete Part 3 on page 2.
Social Security Number (of Individual or Owner of Sole Proprietorship)	
			
Is taxpayer a newly created business this year?	

	Yes	

Federal Employer Identification Number (FEIN)
(If a Sole Proprietorship, Enter FEIN if it has one)

	No

If taxpayer is a business, what is the principal business activity? __________________________________________________________
Did taxpayer file a North Dakota income tax return for the most recent tax year?	
(If a newly created business this year, skip this question.)

	Yes	

	No

If no, explain __________________________________________________________________________________________
Does (or will) taxpayer sell tangible personal property or services for which North Dakota sales tax must be	
collected from the customer?
If yes, has taxpayer applied for or obtained a North Dakota sales tax permit?	

	Yes	

	Yes	

	No

	No

If no, explain ____________________________________________________________________________________________
Does (or will) taxpayer have employees whose wages are subject to North Dakota income tax withholding?	
If yes, has taxpayer registered for North Dakota income tax withholding?	

	Yes	

	Yes	

	No

	No

If no, explain ____________________________________________________________________________________________
Taxpayer’s Signature	

Date

Printed Name of Taxpayer	

Contact Telephone Number

Mail request to:	 Individual Income Tax Section		
	
Attn: Supervisor
	
Office of State Tax Commissioner		
	
600 E. Boulevard Ave.	
	
Bismarck ND 58505-0599

Or fax request to: 701.328.1942

Important: The renaissance zone certificate of good standing or state tax clearance record will only be sent to the
taxpayer or to the taxpayer’s designated representative shown on a North Dakota Form 500 attached to this form.

Request for Renaissance Zone Certificate of Good Standing or
State Tax Clearance Record
SFN 28220 (4-2020) page 2

Part 3 - Responsible Person Information
Except for an individual or sole proprietorship (Part 2, Box 1), all taxpayers must complete Part 3. Enter the name and
social security number of any officer, partner, governor, or managing member who is responsible for the taxpayer’s tax
obligations. If there is more than one responsible person, include all all of them.
	

Name of Responsible Person	

Social Security Number	

PRIVACY ACT NOTIFICATION
In compliance with the Privacy Act of 1974, disclosure of a social security number or Federal Employer Identification Number (FEIN) on this
form is required under N.D.C.C. §§ 57-01-15 and 57-38-42, and will be used for tax reporting, identification, and administration of North
Dakota tax laws. Disclosure is mandatory. Failure to provide the social security number or FEIN may delay or prevent the processing of this
form.