Date Business Discontinued
Date Business Sold
Name of Purchaser
Business Location Change
Mailing Address Change
Change in Name of Business
INSTRUCTIONS:
Vendor Compensation is Deductible Only When Payment is not Delinquent
Penalty is 5% of Tax for Each 30 Days or Fraction of Month Thereof of Delinquency Not to Exceed 25%
Interest is Calculated from Date Due until Paid