Tax Clearance Form - Indiana Department Of Revenue
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1
2Tax Clearance Form
State Form 53227
(R3 / 8-09)
Permit Number
Hearing Date
Expiration Date
______ /______ /_______
______ /______ /_______
1
FEDERAL TAX I.D. #
State Tax I.D. #
2
Coporate, partnership, or sole proprietor name:
Name
Phone Number
Mailing or Street Address
City
State
Zip Code
County
3
Business trade name, (d.b.a):
Name
Phone Number
Location Address
City
State
Zip Code
County
4
Is this business registered as a not-for-profit
If YES, what is your number?
organization in Indiana?
YES
NO
5
Type of Ownership:
Sole Proprietorship
Corporation (For Profit)
Other (Specify)
Partnership
Government
6
All coporations, please answer the following questions. Otherwise, go to question #7.
State of Incorporation:
Date of Incorporation:
State of Corporate Domicile:
If not an Indiana Coporation, enter date
Accounting Period
authorized to do business in Indiana:
year ending date:
MONTH
DAY
7
LIST BELOW ALL BUSINESS OWNERS / PARTNERS / OFFICERS: ATTACH A SEPERATE SHEET IF MORE THAN THREE.
Name. (Last, First)
Title Address
City
State
Zip Code Social Security Number
1.
2.
3.
8
Has this business entity ever filed bankruptcy
YES
NO
If so, when?
I authorize the Department of Revenue to release the current tax information of the applicant named above to the Alcohol
and Tobacco Commission for the purpose of issuing an ABC Permit with the Statutes of Indiana.
Authorized Signature
Title
Date
This Clearance is valid for thirty (30) days only.
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Parent category: Financial