Form 78-006a/b - Iowa Direct Pay Permit Application

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Iowa Department of Revenue
Iowa Direct Pay Permit Application
https://tax.iowa.gov
1. Location Name/Address
4. Previous Owner
If purchasing an existing business, provide prior owner’s
Federal Employer Identification Number (FEIN)
(If you have applied but not yet received an FEIN, write “applied for”)
name.
Social Security Number (SSN)
5.
Owners, General Partners, Corporate
(Required for sole proprietor or individual single member LLC)
Officers, and Responsible Parties
Print the name, SSN, and address of all individuals who are
Legal name
(Sole proprietor or individual single member LLC, fill in last
name, first name)
owners, partners, officers, or responsible parties. Include
additional sheets if necessary
.
Trade name
(doing business as)
Individual name
Location address (
Must be a street address. Do not write PO Box.)
SSN
City
State
ZIP
Personal address
A list of Iowa counties is available at https://tax.iowa.gov.
IA county name
IA county number
Phone 1
Ext.
Individual name
Phone 2
Ext.
SSN
Fax
Personal address
Email
Date business established
State in which established
6.
Signature
Note: This application must be signed by an owner, a
partner, or a corporate officer listed above.
2.
Mailing Name/Address
To qualify for a direct pay permit, this affidavit must be
Send mail to the address provided below.
signed.
Name
I hereby certify that during the last two years prior to
application for this direct pay permit we have paid sales and
Mailing address
use tax (excluding local option tax) to the Iowa Department
of Revenue or to vendors in an amount averaging more than
City
State
ZIP
$4,000 in a semi-monthly period.
Phone 1
Ext.
Signature
Phone 2
Ext.
Print name
Email
SSN
Date
3.
Type of Ownership (must check only one)
Contact name
Phone
Corporation
Email
Partnership
Association
Government
Limited liability co (LLC) filing on corporation(1120),
Incomplete applications will delay processing.
S corporation(1120), or partnership income return(1065)
Individual single-member LLC filing on individual income
return(1040, Schedule C)
Sole proprietor (one person and not an LLC)
78-006a (07/22/15)

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