STATE  OF NORTH DAKOTA

                                          OFFICE   SOF                  TATE  T AXC               OMMISSIONER
                                                                 Brian Kroshus, Commissioner

                                          Questionnaire Regarding Activities in North Dakota
                                                             During The Past Ten Years
             Complete the information requested below and mail to:                                North Dakota State Tax Commissioner
                                                                                                  Corporate Income Tax Section
                                                                                                  600 E. Boulevard Ave., Dept. 127
                                                                                                  Bismarck, North Dakota 58505-0599
1.  Exact Corporation name and d/b/a name:                                                                             Phone:
     Street address of Corporation
     City                                                               State                        Zip Code
2.  Federal Employer Identifi cation No.:                               3. State of Incorporation:                 4. Date of Incorporation:

5.  Type of Corporation  (C Corporation, S Corporation, LLC):

6.  Nature of business and description of property and/or services sold:

7.  Principal business activity in North Dakota:

8. Date qualifi ed to do business in North Dakota, if registered:                                 9. Date North Dakota activity began:

10.  Have you ever fi led returns with North Dakota?  If yes, enter date of last return and exact name under which return was fi led:
                                  Yes         No                       Date                                                        Name
Corporate Tax
Sales Tax
Workman’s Compensation
11.  List names and addresses of your three largest customers in North Dakota:
     (a)
     (b)
     (c)
12.  Amount of sales for last three years:
   Tax Year Ended                                 Total Everywhere                                                                 Total North Dakota
   ____/____/____                               $ ____________________________                                $ _____________________________________
   ____/____/____                               $ ____________________________                                $ _____________________________________
   ____/____/____                               $ ____________________________                                $ _____________________________________

13.  Net income (before net operating loss deduction) on federal tax return for last three years:
     20 ________    $ ____________________     20 ________     $ ____________________     20 ________    $ ____________________

14.  List all states your corporation conducts business activities in: ___________________________________________________________________________________
15.  List all subsidiaries, divisions, or parent corporations operating within North Dakota:
                      Name                                             Relationship                                                Address
(a) __________________________________              _____________________________                      _______________________________________________
(b) __________________________________              _____________________________                      _______________________________________________
(c) __________________________________              _____________________________                      _______________________________________________

28819

                                          600 E. BOULEVARD AVE., D      EPT. 127, BISMARCK, NORTH DAKOTA 58505-0599
          701-328-2770    FAX: 701-328-3700    HEARING/SPEECH IMPAIRED                      : 800-366-6888    WWW.TAX.ND.GOV           TAXINFO@ND.GOV

Summary Of North Dakota Business Facilities And Activities
                                                                                                                                                                                              Page 2
Answer All The Following Questions As They Relate To The Corporation’s Activities In North Dakota During 
The Past Ten Years. Space Is Provided On The Last Page Of The Questionnaire For Detailed Explanation Of 
All “Yes” Answers. Number Your Explanation To Agree With The Number Of The Question Answered.

16. Does the company now have, or has it at any time had, an offi ce ( ), agency ( ), warehouse ( ) or other place of business ( )                                                              Yes No
in North Dakota? If yes, detail should give location and dates .................................................................................................

17. Does the company or any affi liated company hold title (or has it in the past held title) to any tangible property or realty
located and/or used in North Dakota (such as merchandise inventory, motor vehicles, offi ce or industrial equipment, etc.)?
If yes, detail should give location and dates ..............................................................................................................................

18. Does the company or any affi liated company lease or rent (or has it in the past leased or rented) any tangible property or
realty located and/or used in North Dakota (such as warehouse space, motor vehicles, offi ce space, industrial equipment,
etc.)? If yes, detail should give location and dates ....................................................................................................................
a) In what name was the aforementioned property licensed or listed for tax purposes?
______________________________________________________________________________________________
______________________________________________________________________________________________
19. Have you licensed intangible rights for use in North Dakota or sold real estate, services or intangibles in North Dakota? If
yes, detail should give location, dates and description of property, service or intangibles. ......................................................

20.  Does the company now have or has it ever had consigned inventory in North Dakota? ..........................................................

21.  Did title to any property, located in North Dakota, remain with the company until the contract price was fully paid? ...........

22.  Does the company maintain a security interest in any products sold or located in North Dakota? ..........................................

23.  Did the company have title to goods present in North Dakota on trial or approval? ................................................................

24.  Does the company have, or has it ever had, company owned advertising material in North Dakota? .....................................

25.  Does the company do any localized advertising (cooperative or otherwise) in North Dakota? ...............................................

26.  Does the company reserve the right of inspection of the customer’s facilities or the products after delivery? ........................

27.  Does the company pick up damaged or returned merchandise in North Dakota from customers in this state? .......................

28.  Were any contracts ever executed by the company in North Dakota? If yes, detail location, dates and value of contracts. ....

29. Does your company ever submit bids to potential customers in North Dakota in which you offer to sell goods or services
based upon conditions specifi ed therein? ..................................................................................................................................

30. Does the company have any employees or other representatives (resident or non-resident) who solicit sales, perform
services, promote the company’s products or otherwise act on the company’s behalf in North Dakota?  If yes, give name,
address, relationship and brief description of duties or responsibilities on attached page. .......................................................

31. Does the company compensate such representatives or employees by straight commission ( ) , salary plus commission ( ),
expense account ( ), other ( ), (please explain)? _________________________________________________________

32. Do you have a standard form of written agreement with employees in North Dakota? If yes, please enclose a copy for our
records.......................................................................................................................................................................................

33.  Do employees representatives maintain an offi ce in their home or elsewhere? ........................................................................
(a) List it as a business address? ................................................................................................................................................
(b) Receive business calls there? ...............................................................................................................................................
(c) Store inventory there? ..........................................................................................................................................................
Dollar amount of inventory _______________
(d) Store samples there? ............................................................................................................................................................
Dollar amount of samples _______________ ................................................................................................................

                                                                                                                                                                                               Page 3

                                                                                                                                                                                           Yes No
 (e) Use offi ce equipment (computer, typewriter, furniture, etc.) supplied by company? ..........................................................
   If yes, value of equipment in North Dakota ________________
 (f) Receive any offi ce expense reimbursement from the company? .........................................................................................

34.  How do your customers in North Dakota usually transmit their purchase order to your company?
   By mail? ............................................................................................................................................................................
   By handling it through your representative? .....................................................................................................................
   Other (please explain) ______________________________________________________ ..........................................

35.  Does your company have a toll free telephone number available for use by North Dakota residents?
 If yes, please provide ______________________

36.  Does taxpayer contract for the use or right to use any research facility situated in  North Dakota? ........................................

37.  Does your company have contracts with third parties to build, install, repair, or service equipment or products in
 North Dakota? ...........................................................................................................................................................................

38.  How are deliveries made into North Dakota?
   By common carrier? ..........................................................................................................................................................
   By your vehicle? ................................................................................................................................................................
   If by your vehicle, are such vehicles owned or leased by your company? ___________________________________
   Are deliveries to customers in North Dakota always made from an out-of-state location? ..............................................

39.  Do employees or representatives engage in any of the following activities in North Dakota:
 (a)  Receive purchase orders when calling upon customer? ....................................................................................................
   If yes, do they have authority to approve or reject the order? ...........................................................................................
 (b)  Accept or secure deposits or downpayments? ...................................................................................................................
 (c)  Collect installments and/or delinquent accounts? .............................................................................................................
 (d)  Investigate or approve credit? ...........................................................................................................................................
 (e)  Repossess the company’s products? ..................................................................................................................................
 (f)  Authorize credits, warranty adjustments or repairs? .........................................................................................................
 (g)  Accept damaged or returned merchandise from customers? ............................................................................................
   If yes, do they resell the merchandise to other customers? ...............................................................................................
 (h)  Make adjustments for returned or damaged merchandise? ...............................................................................................
 (i)  Check inventories of customers or distributors in North Dakota? ....................................................................................
 (j)  Inspect or have the right to inspect the marketing of your products or any use of your trademarks or tradenames?
 (k)  Plan dealer promotions? ....................................................................................................................................................
 (l)  Arrange cooperative advertising agreements with customers? .........................................................................................
 (m) Conduct lectures, fi lms etc., promoting or demonstrating company’s products or service to a fi nal consumer? .............
 (n)  Investigate, recommend, or appoint potential dealers, agents, or distributors of the company? ......................................
 (o)  Call on dealer’s customers accompanied by dealer’s salesmen? ......................................................................................
 (p)  Perform engineering functions? ........................................................................................................................................
 (q)  Make “on the spot” sales of any items carried by them? ..................................................................................................
 (r)  Conduct training courses or schools for your customers, agents, distributors, etc.? ........................................................
 (s)  Provide sales or service manuals to customers, distributors, agents, etc.? .......................................................................
 (t)  Hire, train, or supervise personnel? ...................................................................................................................................
 (u)  Supervise installation of company’s products? .................................................................................................................
 (v)  Periodically or occasionally service or repair equipment or property of your customers? ...............................................
 (w)  Perform any installation or construction work? ................................................................................................................
 (x)  Handle complaints, trouble shoot or give advice other than transferring to headquarters? ..............................................
 (y) Hold meetings?..................................................................................................................................................................
 (z)  Sell, or represent, other lines of merchandise besides yours? If yes, explain in detail .....................................................
 (aa)  Any other activities not fully explained by the above questions? If yes, explain in detail ...............................................  

                                                                                                                                  Page 4

Explain all “yes” answers in detail. Refer to questions answered by number. If the space provided is not suffi cient, please attach
additional pages with references to applicable questions.

                                                         PRIVACY ACT NOTIFICATION
In compliance with the Privacy Act of 1974, disclosure of a social security number or Federal Employer Identifi cation Number (FEIN) on 
this form is required under N.D.C.C. §§ 57-01-15 and 57-38-32, and will be used for tax reporting, identifi cation, 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.

I declare under the penalties of perjury that I have examined this material and that the answers to the
questions are to the best of my knowledge and belief, true, correct and complete.

______________________   _______________________________________   __________________________
Date                    Signature of Offi cer                                     Title

                        _______________________________________
                                                         Written Name