Vt Form Br-400 (Formerly Form S-1) - Application For Business Tax Account
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5Vermont Department of Taxes PO Box 547
Montpelier, VT 05601-0547
*154001100*
Phone: (802) 828-2551
VT Form
Application for
BR-400
* 1 5 4 0 0 1 1 0 0 *
BUSINESS TAX ACCOUNT
(Formerly Form S-1)
TYPE OR PRINT - Please read instructions and answer all questions completely.
PART 1 - APPLICANT INFORMATION
1. Business Type (check one)
Sole Proprietor
Single Member LLC
LLC
(Ind., Married Couple or Civil Union)
Partnership
S-Corporation
C-Corporation
Federal Government
VT State Government
501(c)(3)
Other ______________________________________
2. Business/Entity Name
If Sole Proprietorship, enter Full Legal Name of Proprietor*
Last Name
First Name
M. I.
3. Federal Employer ID Number
4. Social Security Number
(Sole Proprietorship only)
5. Legal or Trade Name of Business (d/b/a)
6a. Primary 6-digit NAICS Number
6b. Brief description of business
7. Mailing Address of Business
8. City
State ZIP
9. Physical Address of Business (Do not enter PO Box)
10. City
State ZIP
11. Telephone Number
12. Fax Number
13. E-mail Address
14. Date authorized to do business in Vermont
15. State of Incorporation
____ / ____ / ________
by Vermont Secretary of State
(LLC, Partnership,S or C Corp)
mm
dd
yyyy
16. Business Activity (Check all that apply in Vermont)
Manufacturer
Wholesale
Service
Retail
Hotel / Motel / Bed & Breakfast
Construction
Restaurant
Other _________________________
*If married or civil union, please complete Schedule BR-400A for additional owner/member.
Form BR-400 (formerly Form S-1)
Page 1 of 3
Rev. 08/15
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