Tax Certification For Vermont Broker-Dealer Firm - Vermont Securities Division printable pdf download

Tax Certification For Vermont Broker-Dealer Firm - Vermont Securities Division

VERMONT SECURITIES DIVISION

Firm Name: ________________________________

CRD #: __________________________________

TAX CERTIFICATION FOR BROKER-DEALER FIRM

The Vermont Legislature has passed a law which provides that a professional license, including registration as a

broker-dealer, may not be issued or renewed unless the broker-dealer certifies that it is in good standing with the

Vermont Department of Taxes. "Good standing" means that no taxes are due, the tax liability is on appeal, the

taxpayer is in compliance with the payment plan approved by the Commissioner of Taxes, or the licensing authority

determines that immediate payment of taxes would impose an unreasonable hardship (32 V.S.A. Section 3113).

The maximum penalty for perjury is fifteen years in prison, a $10,000 fine, or both.

********************************************************************************

I hereby certify, under the pains and penalties of perjury, that this firm is in good standing with respect to or in full

compliance with a plan to pay any and all taxes due the State of Vermont as of the date of this application. I further

certify that all information contained in the application is true and accurate to the best of my knowledge.

Date: ________________

Signature:

_____________________________________

Title:

_____________________________________

Type/Print Name: _____________________________________

Business Address: _____________________________________

_____________________________________

*********************************************************************************************************

THIS FORM IS TO BE USED FOR FIRM ONLY - NOT INDIVIDUAL SALES REPRESENTATIVES.

PLEASE NOTE: IF YOU ARE NOT PRESENTLY IN GOOD STANDING WITH THE VERMONT DEPARTMENT OF TAXES,

YOU MUST CONTACT THE COMPLIANCE DIVISION, COLLECTIONS AT 802-828-2518 TO MAKE ARRANGEMENTS TO

OBTAIN TAX CLEARANCE FROM THAT DEPARTMENT.

On-line Form 03/02

Tax Certification For Vermont Broker-Dealer Firm - Vermont Securities Division