QSBS Rollover Onboarding And Entity Creation
General Information
Information about the principal agent of your new Entity (Your info.)
Name as it Should Appear on Legal/Entity Documents
First Name
Middle Name
Last Name
DOB
-
Month
-
Day
Year
Date
Business Contact Email
example@example.com
Phone Number
US Citizenship Status
Please Select
US Citizen
Permanent Resident
Non-Resident
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cash Contribution to Rollover:
Ex. $8,000,000
60-day Rollover Deadline Date (If Known)
Ex. August 15 (Should be 60 days after wire received)
Entity Creation Details
This is the information that will be used to establish your new entity. You will wholly control this entity - it is the one that will issue your new QSBS stock and enter the new business.
What Will be The Name of Your New Entity?
Ex. Doe Tech
If Your First Choice is Unavailable, Option Two:
Ex. Doe Tech Management
If Your Second Choice is Unavailable, Option Three:
Ex. D Tech Excel
EIN Creation Details
This information will be used to establish an EIN for your new entity. Some fields are pre-filled for you.
I Acknowledge That The Trade Name of This Entity Will Be The Same as It's Legal Name Above
Yes
No
Physical Address of entity (Ex. The Member's Home Address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
Mailing Address (If Different than Above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Principal Business Activity
Holding co and new technology business
Principal Line of Merchandise Sold or Specific Services Provided
Holding company
Reason for Applying for EIN
Starting a new business
Will the Entity Have W2 Employees?
Yes
No
Does your business own a highway motor vehicle with ataxable gross weight of 55,000 pounds or more?
Yes
No
Does your business involve gambling/wagering?
Yes
No
Does your business need to file Form 720(Quarterly Federal Excise Tax Return)?
Yes
No
Does your business sell or manufacture alcohol, tobacco, or firearms?
Yes
No
Do you have, or do you expect to have, any employees who will receive Forms W-2 in the next 12 months?
Yes
No
Month/Year wages will first be paid:
Will employment tax liability be $1000 or less in a full calendar year?
Has the applicant entity shown above ever applied for and received an EIN?
Yes
No
Sharing of Information and Acknowledgments
I understand that the above information will be reviewed by managers of QSBSrollover.com and shared with the Corporate Services Firm, DBO (www.getdbo.com) for entity filing, registered agent establishment, operating agreement completion, and other relevant filings for entity creation and EIN establishment. I also acknowledge that if I am not comfortable providing the above information via this secure form, I can contact DBO directly to provide these details. Submission of this form along with the electronic signature provided below grants the release of this information for the above stated purposes, and no other, except with permission from the undersigned. For questions please contact Brady@QSBSrollover.com.
Name of Signor
*
First Name
Last Name
Signature of Signor, Recognition of Acknowledgments
*
Please verify that you are human
*
Submit
Should be Empty: