Form Vtc - 9541 - Application For Vendor Tax Clearance Certificate

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NEW YORK CITY
DEPARTMENT OF FINANCE
G
APPLICATION FOR VENDOR TAX CLEARANCE CERTIFICATE
TM
Finance
IMPORTANT: YOU MUST SUBMIT ALL OF THE DOCUMENTATION LISTED BELOW AND COMPLETE THIS APPLICATION IN
ORDER FOR US TO ISSUE A TAX CLEARANCE CERTIFICATE. INCOMPLETE APPLICATIONS WILL BE RETURNED.
TO SUBMIT THIS FORM IN PERSON, VISIT 66 JOHN STREET, 2
FLOOR, NEW YORK, NY 10038
ND
Name of
Vendor:
Agency that issued your Vendor License:
Department of Health
Department of Consumer Affairs
K
K
Corporation
Partnership
Self-Employer/Sole Proprietorship
K
K
K
Business
Type:
Other:
K
(Explain)
_________________________________________________________________________________________________________________
For individuals and Sole Proprietors, enter
For Sole Proprietors with employees, Partnerships and
your Social Security Number (SSN):
Corporations, enter your Employer Identification Number (EIN):
Note: Sole Proprietors with an EIN must also provide their SSN
Vendor License Number:
New York State Certificate of Authority Number (Sales Tax ID #):
Type of Sales:
Mailing Address:
City and State:
Zip Code:
Daytime
Providing us with a daytime phone number may speed our processing
N
O
of your application in the case where your application is incomplete.
Telephone Number:
T
E
Do you have vehicles with commercial plates that you use in connection with your vending business?.................
YES
NO
K
K
If “YES”, list all such plate numbers: _____________________________________________________________________________
REQUIRED DOCUMENTATION
In order to have your application processed, you must attach the following documentation:
1. A copy of your:
2. A copy of your most recently filed Federal Income Tax Return
For individuals/sole proprietors: Form 1040, 1040A or
a. Vendor License or permit (front and back)
G
1040EZ, including Schedule C
b. For individuals/sole proprietors: Social Security Card
For partnerships: Form 1065
c. New York State Certificate of Authority
G
For corporations: Form 1120
G
NOTE: If it is now between January 1st and April 15th, you
must submit the tax return that you filed last year.
CERTIFICATION
I hereby certify that the statements made herein are to the best of my knowledge true, correct and complete. In addition, I affirm that
the attached returns have been properly filed.
___________________________________________________
___________________________________________________
_________________________
Signature of Taxpayer
Print Name
Date
MAILING INSTRUCTIONS
You may mail your completed application with all the required documentation to:
NYC Department of Finance, Collections Division, Vendor Tax Clearance Section
59 Maiden Lane, 28
Floor, New York, NY 10038 - Attn: Bernadette Thomas
th
VTC - 9541 rev. 08.17.10

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