ST 900 
                                                                                                                                 Rev. 11/21

               Audit Division
               P.O. Box 183014 
               Columbus, OH 43218-3014

                        Application for an Ohio Direct Payment Permit
The undersigned consumer hereby makes application pursuant to Ohio Revised Code (R.C.) section 5739.031 for authority to pay the 
sales tax levied by R.C. sections 5739.02, 5739.021, 5739.023 and 5739.026, and the use tax levied under R.C. sections 5741.02, 
5741.021, 5741.022 and 5741.023.
Please type or print clearly. Please complete all sections or the application may be denied.

1. Legal entity name                                   Trade name 
2. Tax return mailing address
3. Person to contact regarding application (include telephone no. and e-mail address)

4. Federal employer identification number, or if none assigned for reporting federal taxes, please enter your Social Security number.

FEIN                                                        Social Security number
5. Check whether business operates as:       Sole proprietor          Partnership/LLP          C corporation           Fiduciary 
      Limited liability company          S corporation 
6. If it is a partnership/LLP or limited liability company, provide the names and addresses of the partners or members:

Name                            Street address              City                                 State           ZIP code

Name                            Street address              City                                 State           ZIP code

Name                            Street address              City                                 State           ZIP code
If more than three, attach a separate sheet listing the remaining partners/members’ information and check the box: 
7. If it is a C corporation or an S corporation, provide the names and addresses of the officers:

Name/title                      Street address              City                                 State           ZIP code

Name/title                      Street address              City                                 State           ZIP code

Name/title                      Street address              City                                 State           ZIP code
If more than three, attach a separate sheet listing the remaining officers’ information and check the box: 
8. Business description:

9. NAICS code           Estimated annual amount and number of taxable purchases: 
                                                                                                 $ Amount          # of transactions
 10. Number of plants, divisions or other facilities to be included under this application:
  Name                                                 Name 
  Address                                              Address 
If more than two, attach a separate sheet listing the information for the remaining locations and check the box: 

                                                       - 1 -

                                                                                                                                      ST 900 
                                                                                                                                      Rev. 11/21

 11. Number of plants, divisions or other facilities in Ohio not to be included under this application: 
   Name                                                         Name 
   Address                                                      Address 

   Direct payment # 98 -                                        Direct payment # 98 - 
   Consumer’s use tax #  97 -                                   Consumer’s use tax #  97 - 
   None                                                         None           
   If more than two, attach a separate sheet listing the information for the remaining locations and check the box: 
I hereby declare that this form has been examined by me and to the best of my knowledge and belief is true, correct, and complete.

   Signed                                                       Title 

   Date                                                         Phone number 

                              MAIL APPLICATION TO:                                          
                              Ohio Department of Taxation                
                              Attention: Audit Support                                         
                                                                Audit Division                                                        
                                                             P.O. Box 183014                                                        
                              Columbus, Ohio 43218-3014

                                                             UPS/Fed Ex, etc.
                              4485 Northland Ridge Blvd.
                              Columbus, OH 43229
                              OR FAX APPLICATION TO:
                              Ohio Department of Taxation             
                              Attention: Audit Support
                                                                Audit Division
                                                             (206) 984-9824

                                                                 - 2 -

                                                                                                                      ST 900 
                                                                                                                      Rev. 11/21

                                           Taxpayer Information Report
Instructions: Please complete all sections of this form with the requested information.
1.  Ohio license/charter number (issued by the Ohio Secretary of State): 
2.  Check the box for each type of Ohio tax return filed. In addition, provide the Ohio account number for each type of tax (attach a sepa-
 rate list if there are numerous accounts).
             Tax Type                      Ohio Account Number                          Effective Date Date Closed
 
 Sales Tax/Seller’s Use                                                                      
 Consumer’s Use/Direct Pay                                                                   
 Financial Institution
 Petroleum Activities
 Pass-through Entity (use FEIN)                                                              
 Employer Withholding
 Individual Income (use SSN)                                                                 
 Commercial Activity

3.  Provide a list of all entities where the taxpayer, directly or indirectly, (i) owns more than 50% of the voting stock of a corporation, or 
 (ii) has more than a 5% ownership interest in a pass-through entity, that is conducting business in Ohio (attach a separate list if more 
 space is needed).
                         Entity Name                                                   FEIN            % of Ownership
                                            
4.  Provide a list of all entities which, directly or indirectly, (i) own more than 50% of the taxpayer’s voting stock, or (ii) have more than a 
 5% ownership interest in the taxpayer that is a pass-through entity (attach a separate list if more space is needed).
                         Entity Name                                             FEIN                  % of Ownership

5.  Has the taxpayer filed for protection under a U.S. Bankruptcy Court?  Yes No 
 If yes, provide the date of filing 

                                            - 3 -

                                                                                                                               ST 900 
                                                                                                                               Rev. 11/21

                                  Responsible Party Questionnaire
We ask that each individual who was either: 1) an officer, member, manager or trustee; or 2) an employee (having control or supervision 
of or charged with the responsibility of filing returns and making payment) of the business entity complete this questionnaire.
1.  Answer the following questions. If additional space is necessary, attach additional sheets. 

Who is responsible for the overall fiscal re- Who prepares Ohio business tax reports/        Who has the authority to sign checks to 
sponsibilities?                               returns?                                       pay for business tax liabilities?

Who actually performs the execution of the    Who assigns the responsibility to file Ohio    Who actually signs checks to pay for busi-
overall fiscal responsibilities?              business tax reports/returns?                  ness tax liabilities?

Who has the authority to  prepare Ohio        Who  actually  files  Ohio  business  tax  re- Who assigns the responsibility to sign 
business tax reports/returns?                 ports/returns?                                 Ohio business tax returns/reports?

Who has the authority to assign the re-       Who has the responsibility  for retaining,  Who exercises management control or au-
sponsibility  for exercising  management  directing  or otherwise  exercising control  thority over employees who were respon-
control or  authority over employees who  over outside accountants, bookkeepers,             sible  for  preparing,  signing  or  filing  Ohio 
are responsible  for  preparing, signing or   or other persons who are charged with fil-     business tax reports/returns?
filing Ohio business tax reports/returns?     ing the Ohio business tax reports/returns?

2.  Provide a list of all shareholders or members that owned more than 5% of the value of the business including their Social Security 
number and home address.

Individual / Shareholder /Member              SSN                                               Home Address

                                                              - 4 -