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This form is effective beginning with the January 1 to June 30, 2017, accounting period (2017/1) If you are filing for a prior accounting period, contact the Licensing Division for the correct form.

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Gather all necessary documents containing personally identifiable information (PII) such as your full name, date of birth, address, and social security number.

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Once you have completed filling out the form with your PII, securely submit it through the designated method.

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What is by providing pii you?

By providing pii you is a process of submitting Personally Identifiable Information.

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Anyone who collects or processes Personally Identifiable Information is required to file by providing pii you.

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By providing pii you requires reporting of basic information such as name, address, contact details, and other Personally Identifiable Information.

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