
1 BUSINESS INFORMATION (Please Type or Print)
BUSINESS NAME EMPLOYER IDENTIFICATION NUMBER
BUSINESS ADDRESS
STATE OF INCORPORATION FOR BUSINESSES INCORPORATED IN ALABAMA, ENTER COUNTY OF INCORPORATION DATE OF INCORPORATION
SECRETARY OF STATE ENTITY ID DAYTIME TELEPHONE NUMBER EMAIL ADDRESS
____ ____ ____ — ____ ____ ____ ( )
2 REQUESTOR (Please Type or Print)
NAME
ADDRESS (THE CERTIFICATE OF COMPLIANCE WILL BE MAILED TO THIS ADDRESS.)
DAYTIME TELEPHONE NUMBER FAX NUMBER EMAIL ADDRESS
( ) ( )
3 TO BE COMPLETED BY NON-PROFIT COMPANIES ONLY:
a If entity is not required to file a Business Privilege Tax Return, check this box. .......
អ
b If entity not required to file an Income Tax Return and files a
Form 990 (does not include 990T) for Federal purposes, check this box. ............
អ
4 FOR SINGLE MEMBER LIMITED LIABILITY COMPANIES THAT ARE DISREGARDED
OWNER NAME
OWNER EMPLOYER IDENTIFICATION NUMBER
NOTE: This field can be a Federal Employer Identification Number (FEIN) or Social Security Number (SSN).
Alabama Department of Revenue
Certificate of Compliance
4227 Gordon Persons Building
50 North Ripley Street
Montgomery, AL 36132
Fax: (334) 242-1030
NOTE: If you have questions concerning the completion of this form, please call (334) 242-1189.
FORM
COM: ACC
10/2015
FOR INFORMATIONAL PURPOSES ONLY