CAT RTFS
                                                                                                 Rev. 11/12

          P.O. Box 16158
          Columbus, OH 43216-6158

          Commercial Activity Tax – Request to File Separately*

Primary taxpayer’s name

Address 

City                                                        State                        ZIP code

FEIN or Social Security no.                                 CAT account no. 

  Member requesting to fi le separately 

  Address 

  City                                                      State                        ZIP code

  FEIN or Social Security no.                               CAT account no. 

  Reason for request to fi le separately (must list specifi c reasons/issues)
  ❑ Check here if continued on attached page

  Note: This request may be made only by combined taxpayer groups. If this request is granted, the member requesting to 
  fi le separately may not elect to consolidate with other members of the same or a different taxpayer group. The tax com-
  missioner may revoke special fi ling approval at any time.

Effective date of separate fi ling (if different from the succeeding tax period)
Note: Special approval by the tax commissioner is required for the separate fi ling to begin with the current tax period.  
Please attach a letter documenting reasons for this request.
Primary taxpayer and member agree to the following: The separately fi ling member may not claim any of the group’s 
$1 million annual exclusion. The member will fi le as a separate taxpayer and will be subject to the applicable tax rate on all of 
the member’s taxable gross receipts without any exclusion. The separately fi ling member is fi nancially sound and currently 
able to pay the commercial activity tax. All members, including the separately fi ling member, remain jointly and severally 
liable for the combined group’s tax liability.
I hereby declare the above to be true and correct to the best of my knowledge and belief.

Primary taxpayer representative                        Signature                         Date (MM/DD/YY)

Representative of member requesting to fi le separate  Signature                          Date (MM/DD/YY)

Contact telephone no. (required)                                 E-mail

Please send this request to: Ohio Department of Taxation, Business Tax Division-CAT RTFS, P.O. Box 530, Columbus OH 
43216-0530 or fax to (206) 666-4462.
*This form is created pursuant to Adm. Rule 5303-29-08.