Statement Relating to Manufacturing Activities - Massachusetts

Form 355Q

Statement Relating to

Manufacturing Activities

Rev. 7/99

Massachusetts

Department of

Revenue

Name and address of corporation Federal Identification number

Date of incorporation

State of incorporation

List all Business Locations in Massachusetts

Location Activity performed at each location

(city/town) (sales, repair, manufacturing, etc.)

Address of principal place of business

Address of principal office in Massachusetts

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:

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.

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