Request For Renewal Of Registration - Department Of Licensing And Consumer Affairs Page 2
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1
2FORM 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
infonnation 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 ofAct 5060.
1.
BUSINESS NAME:
_
2.
BUSINESS ElN:
_
3.
OWNERS SSN:
SPOUSE SSN:
_
4.
PLEASE INDICA TE: _ _ _ _ _ _ NEW LICENSE
_ _ _ _ _ _ RENEWAL
5.
_ _ _ SELF-EMPLOYED
CORPORA TION
PARTNERSHIP
LLC
LLP
6.
DO YOU HA VE EMPLOYEES?
_
7.
PLEASE CIRCLE FORMS THAT YOU USE:
(1040/8689,1065,1120,941 VI,720VI,720BVI,722 VI, OTHER
(1ist)
_
8.
DA TE BUSINESS STARTED:
LICENSE EXPIRA TION DATE:
_
9.
PERSON REPRESENTING APPLICANT:
_
10. POSITION OF REPRESENTATIVE:
_
11. SIGNATURE:
_
12. MAILING ADDRESS:
_
13. PHYSICAL ADDRESS:
_
14. DATE:
TELEPHONE:
_
REPLY TO: 9601 ESTATE THOMAS, ST. mOMAS, VIRGIN ISLANDS 00802
OR
4008 ESTATE DIAMOND, PLOT 7B, CHRlSTIANSTED, VIRGIN ISLANDS 00820-4421
/5ee back o/Form/or instnlctiollsJ
Revised 2/2009
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