Form Bc-100 - Indiana Business Closure Request
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1Indiana Department of Revenue
BC-100
Indiana Business Closure Request
State Form
52038
R3 / 6-06
TID Number:
FID Number:
Tax Type:
Other
Sales
Withholding
FAB
(Please List)
Owner Name:
Social Security Number:
Corporation Name:
Address:
Daytime Telephone Number:
I certify that I have been out of business or no longer required to be registered for the indicated tax type:
Type
Type
Date
Date
Date
Type
I further certify no sales, withholding, or other tax has been collected since the above date.
I may also be responsible for all liabilities or unfiled returns proven to be due and owed at a later date.
Date
Printed Name
Title
Signature
The Department will neither accept, nor process a BC-100 without proper documentation, attached to this
form, proving the business is closed. Examples of documents the Department will consider acceptable
include the following:
• Minutes of the final board of directors meeting.
• Records of bank accounts closed.
• Articles of dissolution.
• Notarized statement of dissolution from an officer of the business.
• Final utility bills.
• Any proof of dissolution filed with the Internal Revenue Service.
• Books and records or any other pertinent information.
Note: This agency is requesting this disclosure of your social security number in accordance with IC 4-1-8-1.
Questions regarding the completion of this form may be directed to the Indiana Department of Revenue
at (317) 615-2700.
Indiana Department of Revenue
Mail the completed form
Fax the completed form
System Services
(317) 615-2697
with documentation to:
with documentation to:
P.O. Box 6197
Indianapolis, IN 46206-6197
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Parent category: Financial