Form Crl-29 - Real Estate Brokers Affidavit And Schedule In Support Of Gross Receipts Deduction - Virginia Business Tax Division

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REAL ESTATE BROKERS AFFIDAVIT AND SCHEDULE
IN SUPPORT OF GROSS RECEIPTS DEDUCTION
For the period beginning January 1, 2003, and ending December 31, 2003.
TO BE FILED WITH BUSINESS LICENSE APPLICATION ON OR BEFORE MARCH 1, 2004.
Business License # ______________________ Firm’s Name _______________________________________________
Arlington Place of Business ___________________________________________________________________________
AFFIDAVIT
The following brokers, sales agents and others employed by this firm are treated as independent contractors under Federal
Internal Revenue Rules and Regulations. These individuals are required to maintain and pay their Arlington gross receipts
tax under their own account. The amounts listed on the Schedule below (or the attached facsimile schedule of the firm’s
design) accurately reflect all gross income attributable to the above Arlington office with respect to both the firm and its
brokers, sales agents and other employees.
____________________________________________
SIGNATURE OF OFFICER OF FIRM
____________________________________________
NAME AND TITLE OF SIGNING OFFICER
SCHEDULE
Firm’s total gross receipts during 2003 .................................................................................... $ ______________________
Independent Contractors’ gross receipts ................................................................................. $ ______________________
Firm’s adjusted receipts and license basis .............................................................................. $ ______________________
RECIPIENT NAME AND ADDRESS
GROSS SHARE $
OFFICE OF THE COMMISSIONER OF REVENUE – BUSINESS TAX DIVISION
2100 CLARENDON BOULEVARD / SUITE 208 / ARLINGTON, VIRGINIA 22201 / (703) 228-3060
CRL-29
Rev. 12/31/03
(Over)

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