Form Lic1 Application For Tax Filing And Payment Status Report-Licensing printable pdf download

Form Lic1 Application For Tax Filing And Payment Status Report-Licensing

FORM LIC1

GOVERNMENT OF

THE VIRGIN ISLANDS OF THE UNITED STATES

*********0**********

VIRGIN ISLANDS BUREAU OF INTERNAL REVENUE

**********0**********

APPLICATION FOR

TAX FILING AND PAYMENT STATUS REPORT-LICENSING

The applicant identified below hereby requests a letter certifying his or her tax filing and payment status

for the purpose of receiving a new or renewal license from the Department of Licensing and Consumer

Affairs pursuant to Section 101 of Act 5060, codified as Title 27, Section 304, Subchapter (j), Virgin Islands

Code. The applicant authorizes the Virgin Islands Bureau of Internal Revenue to disclose any taxpayer

information related to this application to the Department of Licensing and Consumer Affairs, who may

make such further disclosures as are necessary to carry out the requirements of Act 5060.

BUSINESS NAME:___________________________________________________________________________________

BUSINESS EIN:_____________________________________________________________________________________

OWNERS SSN:__________________________________ SPOUSE SSN:______________________________________

PLEASE INDICATE: _______________ NEW LICENSE

_______________ RENEWAL

_______ SELF-EMPLOYED_______ CORPORATION_______ PARTNERSHIP_______ LLC_______ LLP

DO YOU HAVE EMPLOYEES?________________________________________________________________________

PLEASE CIRCLE FORMS THAT YOU USE:

(1040/8689,1065,1120,941VI,720VI,720BVI,722VI, OTHER(list

____________________________________________

)

DATE BUSINESS STARTED: _______________________ LICENSE EXPIRATION DATE: _____________________

PERSON REPRESENTING APPLICANT: ______________________________________________________________

10. POSITION OF REPRESENTATIVE: ___________________________________________________________________

11. SIGNATURE: _______________________________________________________________________________________

12. MAILING ADDRESS: _______________________________________________________________________________

13. PHYSICAL ADDRESS: ______________________________________________________________________________

14. DATE: ___________________________________ TELEPHONE : ___________________________________________

REPLY TO: 9601 ESTATE THOMAS, ST. THOMAS, VIRGIN ISLANDS 00802

OR 4008 ESTATE DIAMOND, PLOT 7B, CHRISTIANSTED, VIRGIN ISLANDS 00820-4421

[See back of Form for instructions]

Revised 2/2009

Form Lic1 Application For Tax Filing And Payment Status Report-Licensing