Form R-1 - Virginia Department Of Taxation Business Registration Application Page 2
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1
2
3
44.
Complete line 4a, 4b, 4c or 4d, whichever best identifies the business' PHYSICAL LOCATION
IMPORTANT!
(street address) entered on line 3. See the instructions for details on determining locality codes.
Enter the correct locality code. Local sales tax revenue is distributed using this information.
* Locality codes are listed on page 2 of the instructions.
This business is located:
4a. OUTSIDE Virginia in the state (or District) of __________________________________.
4b. INSIDE Virginia, ENTIRELY WITHIN the CITY or COUNTY OF ___________________. *Locality Code ___________
4c. INSIDE Virginia, but NOT ENTIRELY IN ONE LOCALITY:
Partly in the CITY or COUNTY of___________________. *Locality Code ___________, and
Partly in the CITY or COUNTY of___________________. *Locality Code ___________.
4d. Are you a specialty dealer selling in flea markets, gun shows, arts/crafts shows, etc.,
at various locations in Virginia? h Yes
5.
Enter your Federal Employer Identification Number (FEIN) ___ ___
-
___ ___ ___ ___ ___ ___ ___
If not required by the IRS to have a FEIN, enter your social security number ___ ___ ___
-
___ ___
-
___ ___ ___ ___
6.
Enter your four-digit Principal Business Activity Code from page 6 of the instructions ___ ___ ___ ___
- AND - describe the products you SELL or the type of SERVICES you provide:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
7.
Complete this line only if different from line 3, or, if separate mailing addresses are desired for different taxes. If additional space
is needed, attach a separate sheet showing the appropriate address for each tax. A list of tax types is on pages 3 and 4.
Tax Type
Mailing Name
Mailing Address
______________
____________________________
________________________________________
Address
____________________________
________________________________________
City or County
State
ZIP Code (9 digit)
______________
____________________________
________________________________________
Address
____________________________
________________________________________
City or County
State
ZIP Code (9 digit)
8.
If you sell alcoholic beverages, enter your Virginia Alcoholic Beverage Control license number: __________________________
SECTION B:
RESPONSIBLE OFFICER(S)
Section 58.1-1813 of the Code of Virginia provides that a corporate or partnership officer may be held personally liable for any of the
taxes registered on this form if that person willfully fails to pay, collect or truthfully account for the tax, or willfully attempts in any way to
evade, defeat or not pay the tax. Notify the Department of Taxation when there is a change of responsible officers. Notification must be
in writing and include changes in names, addresses and telephone numbers.
9.
Complete this line for each owner, partner, member, corporation officer or trustee. Attach additional pages, if needed. In the case
of a limited partnership, complete this line for each general partner. See instructions.
__________________________________________________________
__________________________________________________________
Social Security Number
Social Security Number
__________________________________________________________
__________________________________________________________
Name
Name
__________________________________________________________
__________________________________________________________
Title
Title
__________________________________________________________
__________________________________________________________
Home Address
Home Address
__________________________________________________________
__________________________________________________________
City
State
ZIP Code (9 digit)
City
State
ZIP Code (9 digit)
Home Phone: (_____) _______________________________
Home Phone: (_____) _______________________________
__________________________________________________________
__________________________________________________________
Social Security Number
Social Security Number
__________________________________________________________
__________________________________________________________
Name
Name
__________________________________________________________
__________________________________________________________
Title
Title
__________________________________________________________
__________________________________________________________
Home Address
Home Address
__________________________________________________________
__________________________________________________________
City
State
ZIP Code (9 digit)
City
State
ZIP Code (9 digit)
Home Phone: (_____) _______________________________
Home Phone: (_____) _______________________________
Page 2
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