Massachusetts Form 355q 2015

Rev. 1/13 Form 355Q Statement Relating to Manufacturing Activities Name and address of corporation Massachusetts Department of Revenue Federal Identification number Date of incorporation NOTE Applications for manufacturing classification must be sent to the Department of Revenue on or before January 31 of the calendar year for which classification is sought to be considered for that year. Applications sent after January 31 will be reviewed for classification for the following calendar year. The date of the postmark made by the United States Postal Service on the envelope in which the application is mailed shall determine the date the application was sent. List all Business Locations in Massachusetts Location city/town Activity performed at each location sales repair manufacturing etc* Address of principal place of business Address of all other locations in Massachusetts Since your corporate purposes include the right to manufacture complete this form and return it to the address on the back so that the corporation may be properly classified* 21 Is your corporation presently engaged in manufacturing in Massachusetts yes no If not what date will such activity begin 22 What is the corporation s principal business activity in Massachusetts 23 Summarize all activities in which the corporation is involved outside of Massachusetts sales manufacturing etc 24 Describe in detail the actual manufacturing process including raw materials used or activities performed by a your employees on your business premises in Massachusetts b others on a contract fee or other basis 25 State the total amount paid to Massachusetts employees and the percentage of that amount received by employees engaged directly in manufacturing. Also state the total number of employees in Massachusetts and the percentage of those engaged directly in manufacturing. The computation of these percentages should not include in the denominator the value or the portion of payroll attributable to in-state headquarter personnel if the corporation owns or rents premises outside the Commonwealth 27 State the original cost of all other machinery located in Massachusetts and not used directly in manufacturing if leased please state the annual rental cost directly in manufacturing. The computation of this percentage should not include in the denominator the value or the portion of space attributable to in-state headquarters if the corporation owns or rents premises outside the Commonwealth percentage of such receipts derived directly from manufacturing include all manufacturing receipts regardless of the destination of the sales 11 State the estimated total gross receipts of the corporation resulting from activity being done in Massachusetts during the current year and the percentage of such receipts being derived directly from manufacturing include all manufacturing regardless of the destination of the sales 12 State any other facts relevant to the corporation s manufacturing activity in Massachusetts to justify its classification as a manufacturing corporation Declaration I hereby state under the penalties of perjury that I have examined the foregoing statements and to the best of my knowledge and belief they are true correct and complete.