Form Ador 74-4001 - Transaction Privilege And Use Tax License Update - Arizona Department Of Revenue
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2Arizona Department of Revenue • License & Registration Section
PO Box 29032 • Phoenix, AZ 85038-9032
Phoenix: (602) 542-4576 • Toll-free: (800) 634-6494
TRANSACTION PRIVILEGE AND USE TAX LICENSE UPDATE
Taxpayer or Legal Business Name on Current License Number (Please print)
STATE FEE: ______________________
License Number
CITY FEE(S): ______________________
(from back page)
Taxpayer I.D. No. (Either Social Security Number (SSN) or Federal Employer I.D. No. (EIN)
TOTAL FEE(S): _____________________
SECTION I. Please check boxes below to indicate the change in your account, and complete
FEE: A $12 state license is required to change the
Sections II through VIII to verify or correct all license information.
business name or location, or to add a business
location, or to obtain a reprint of the license. In addition,
A. Business name or DBA name change
city fees are required if the change or request affects
a license issued in a city for which the Department
B. Mailing address change
collects transaction privilege taxes; also to add a
C. Business location change
license for one of those cities. A list of these cities is
on the reverse of this form along with the applicable
D. Additional business or rental location(s) fi ling consolidated reports
fees. Please indicate the affected cities on the back
E. Duplicate license
and calculate fees above. Make checks payable to the
Arizona Department of Revenue. Please note that no
F. Add city license (see other side)
fees are required for use tax registrants.
SECTION II. BUSINESS NAME AND MAILING ADDRESS
Effective Date: _________________________________
Legal Business Name or Last Name, First Name, Initial
Street No.
Direction
Street Name, P.O. Box or Route No.
City
County
State
Zip Code
(
)
(
)
Resident Phone No.
Business Phone No.
In Care Of
SECTION III.
PHYSICAL LOCATION OF BUSINESS OR RENTAL
Check here if this is added location
Business or DBA Name
Street No.
Direction
Street Name (not P.O. Box or Route No.)
City
County
State
ZIP Code
Is your business located on an Indian reservation?
Yes
No
If “yes”, please tell us which one: ______________________________
SECTION IV.
OWNER INFORMATION (Last Name, First Name, Middle Initial)
Name of Owner, Partner, President or Receiver
Social Security No.
Name of Spouse, Partner or Vice President
Social Security No.
Name of Partner or Secretary
Social Security No.
Name of Partner or Treasurer
Social Security No.
SECTION V.
LOCATION OF RECORDS
(
)
Name of Company or Person to Contact
Phone No.
Street Address (not P.O. Box or Route No. )
City
State
Zip Code
ADOR 74-4001 (9/03)
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