Business License Tax Return Form - Virginia Commissioner Of Revenue - 2004

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2004
Arlington County, Virginia
MAIL THIS RETURN TO:
Treasurer, Arlington County
Ingrid H. Morroy
P.O. Box 1757
Merrifield, VA 22116-9786
Failure to file license tax return
Commissioner of Revenue
Phone: (703) 228-3060
carries a criminal penalty
Email: revenue@co.arlington.va.us
BUSINESS LICENSE TAX RETURN
If you have ceased business: Date ceased: _______________
2003 Gross Receipts: $ ____________________
Name/Address of successor (if any): ___________________________________________________________________
9.
Businesses using installment payment
Check Here
FOR OFFICE USE ONLY
1. Account Number: ______________________________________
See reverse for eligibility
Date you began business in
10.
2. Name: _______________________________________________
Arlington at this location
/
/
___
Last
First
MI
11. Check here if Arlington business is residence:
____________________________________________________
12. Federal EIN or Soc. Sec. # ________________________
(If Corporation, enter Corporate Name)
13. Individual
Partnership
Corporation
Mailing address: ______________________________________
No. / Street
FOR OFFICE USE ONLY
____________________________________________________
City
State
Zip
14. CO #/TN# _____________________________________
3. Arlington business address:
15. Home Address (Individual / Partner / Corporation)
____________________________________________________
______________________________________________
Arlington, VA 222 ________
______________________________________________
Telephone (________)__________________________________
______________________________________________
Name and Address of Registered Agent
4. Trade name __________________________________________
______________________________________________
6. # of Employees
FOR OFFICE USE ONLY
in Arlington ______
______________________________________________
(annual average)
5. Z:
D:
T:
______________________________________________
7. Section 11- ________________ Detail _____________________
State of Incorporation ____________________________
Date of Incorporation or VA Qualification: ___________________
Business classification ________________________________________________________________________________________
8. Detailed Description of Business _________________________________________________________________________________
CHECK BOX AND COMPUTE YOUR TAX AS INSTRUCTED (See back of this form)
16.
Applicant who was in business throughout 2003, enter the gross receipts for 2003 per applicant’s records in Box 20.
17.
Applicant beginning business after Jan. 1, 2003, but prior to Jan. 1, 2004, enter gross in 2003 here $ _____________________
Enter estimated gross in 2004 in Box 20. An adjustment will be made in the succeeding year.
18.
Applicant beginning business on or after Jan. 1, 2004, enter estimated gross receipts from beginning of business to Dec. 31,
2004 in Box 20. An adjustment will be made in the succeeding year.
19.
License tax not based on gross receipts; enter annual tax in Box 21.
20. GROSS RECEIPTS (to nearest dollar)
If gross receipts on this license are:
* $0-$10,000: AMOUNT DUE is $0; Enter $0 on Line 21
21. AMOUNT DUE
$ __ __ __ . __ __ __ . __ __
* $10,001–$50,000: AMOUNT DUE is $30; Enter $30 on Line 21
22. PENALTY (if late)
$ __ __ . __ __ __ . __ __
23. INTEREST (if late)
$ __ __ . __ __ __ . __ __
* $50,001–$100,000: AMOUNT DUE is $50; Enter $50 on Line 21
* Over $100,000: Multiply gross receipts in Box 20 by tax rate.
24. TOTAL DUE
$ __ __ __ . __ __ __ . __ __
Enter AMOUNT DUE on Line 21
DATE:
Print Name/Title
FOR OFFICE USE ONLY
DR
PMD
BY
Signature
/
/
C
BY
DATE
Make checks payable to Treasurer, Arlington County and mail filing
and payment coupon to: P.O. Box 1757, Merrifield, VA 22116-9786.
P
TAG
ED
BY
PLEASE DO NOT DETACH THE FORM FROM THE PAYMENT
TR
BA
DATE
BY
COUPON.
FORM CR-L3 Rev. 12/31/03
Make checks payable to: Treasurer, Arlington County. Please write the account number on your check. Payments may be made by e-check or credit
card over the Internet by visiting the website: Credit card payments may also be made by calling 1-888-
2-PAY-TAX (1-888-272-9829). A service charge, imposed by our service provider, will apply to all credit card transactions based on the amount of each
payment. There is no service charge for payments made by e-check. Regardless of payment method, return this coupon, with return, in the enclosed
envelope.
Contact Person: ___________________________
BL
METHOD OF REMITTANCE:
_____ CHECK
_____ (PHONE) CREDIT CARD
Telephone: _______________________________
Due Date
_____ INTERNET (E-CHECK OR CREDIT CARD)
March 1, 2004
TOTAL AMOUNT REMITTED
$
Email Address: ____________________________
Account #22
Please check here if you would like to receive
“Commissioner’s Alerts” by email.

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