Form 78-006a - Iowa Direct Pay Permit Registration
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1Iowa Department of Revenue
Iowa Direct Pay Permit Registration
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I. LOCATION NAME/ADDRESS
V. OWNERS, GENERAL PARTNERS, CORPORATE
OFFICERS AND RESPONSIBLE PARTIES
Federal Employer ID Number (if any): _____________________
Print the names and Social Security Numbers of all.
Social Security Number: ________________________________
Attach additional sheets if necessary.
Owner Name: _________________________________________
Name: _____________________________________________
Business Name: _______________________________________
SSN: ______________________________________________
Street Address ________________________________________
(not a PO Box)
Title: ______________________________________________
City: ____________________ State: _____ Zip+4: ___________
County Name: __________________ County Number: _____
Name: _____________________________________________
SSN: ______________________________________________
Phone 1: ______________________ Ext. _______________
Phone 2: ______________________ Ext. _______________
Title: ______________________________________________
Telephone Number Required
Name: _____________________________________________
II. MAILING NAME/ADDRESS
SSN: ______________________________________________
If your mailing address is different than the location of your business,
Title: ______________________________________________
complete this section.
Name: _______________________________________________
Name: _____________________________________________
Mailing Address: ______________________________________
SSN: ______________________________________________
City: ____________________ State: _____ Zip+4: ___________
Title: ______________________________________________
Phone 1: ______________________ Ext. _______________
VI. SIGNATURE
Phone 2: ______________________ Ext. _______________
This application must be signed by the owner, one of the partners or
one of the corporate officers listed above. A preparer’s signature is
III. TYPE OF OWNERSHIP (check one)
not acceptable unless he/she is one of the owners or corporate
officers.
Sole Proprietor
Partnership
Corporation
Association
Government
Limited Liability Co
Signature: ____________________________________________
Date Established: _____________________________________
Print Name Here: ______________________________________
State in which Established: ______________________________
Social Security Number: ________________________________
Date: ________________________________________________
IV. PREVIOUS OWNER
VII. CERTIFICATION
If you are purchasing this business, provide previous owner’s name:
To qualify for a Direct Pay Permit, this affidavit must be signed.
____________________________________________________
I hereby certify that during the last two years prior to application
for this Direct Pay Permit, we have paid sales and use tax
(excluding local option tax) to the Iowa Department of Revenue
FOR OFFICE USE ONLY
or to vendors in an amount averaging more than $4,000 in a
COUNTY: ____________________________________________
semi-monthly period.
PERMIT NUMBER
FILER TYPE
Signature: ____________________________________________
____________________________________________________
____________________________________________________
Print Name Here: ______________________________________
____________________________________________________
INCOMPLETE APPLICATIONS
____________________________________________________
WILL DELAY PROCESSING.
BUS CLASS: ______________ OWNER TYPE: ______________
78-006a (12/26/12)
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Parent category: Financial