Form Bt-1 - Business Tax Application Page 7
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12Indiana Department of Revenue
Form BT-1
Business Tax Application
SF 43760
(Revised 9-97)
(Please print legibly or type the information on this application.)
A separate application is required for each business location.
Section A: Taxpayer Information (see instructions on page 1)
Contact the Department at (317) 486-5518 for more information regarding this application.
2.
1.
Federal
If this business is currently registered for any
Identification
Indiana tax under this ownership, enter your
___ ___ ___ ___ ___ ___ ___ ___ ___
Number:
Taxpayer Identification Number:
___ ___ ___ ___ ___ ___ ___ ___ ___ ___
3.
Owner name, Legal name, Partnership name,
Corporate name or Other entity name:
If sole owner (Last name, First name, Middle Initial:
Street Mailing Address:
City:
State:
Zip Code:
County:
4.
Check the type of organization of this business:
Sole Proprietor
Partnership
LLP
Corporation
LLC
Fed Govt
Other Govt
Other
5. All corporations answer the following questions: Otherwise, proceed to Question 6.
A. State of Incorporation:
B. Date of Incorporation:
C. State of Commercial Domicile:
Month
Day
Year
D. If not incorporated in Indiana, enter the
E. Accounting period
D.
date authorized to do business in Indiana.
year ending date:
Month
Day
Month
Day
Year
6.
Owner, Partners, or Officers (Attach separate sheet if necessary.)
Last Name, First Name, Middle Initial
Title
Street Address
City
State
Zip Code
Social Security Number
Social Security Numbers are required in accordance with IC 4-1-8-1.
7.
Name of contact person: (Person responsible for filing tax forms)
8.
Contact person's Daytime Telephone Number:
(
)
EXT
9.
Business trade name or DBA:
(This name and address is for the business location.)
Street Mailing Address:
(P.O. Box numbers cannot be used as a business location address.)
City:
State:
Zip Code:
County:
Township:
Tax District Number:(Motor Vehicle Rental only)
10.
Business Location Telephone Number:
Standard Industrial Code: Please enter a primary and any secondary code(s) that may apply.
11.
(
)
EXT
PRIMARY
Tax(es) to be Registered for this Business Location
(Check all that apply.)
Sales Tax ($25.00 nonrefundable registration fee required per location;
County Innkeepers Tax (Complete Section E.)
complete Section B for a Registered Retail Merchants Certificate.)
Motor Vehicle Rental Excise Tax (Complete Section F.)
Withholding Tax (Complete Section C.)
Prepaid Gasoline Sales Tax ($100.00 registration fee
Out-of-State Use Tax (Complete Section B.)
required for qualified distributors; complete Section G.)
Food and Beverage Tax (Complete Section D.)
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Parent category: Financial