Vt Form Br-400 (Formerly Form S-1) - Application For Business Tax Account Page 3
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5*154001300*
From Form BR-400, Part 1, Lines 2-4
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Business Name __________________________________________
FEIN ___________________
Sole Proprietor Name _____________________________________
SSN ___________________
PART 4 - COMPLIANCE CHECK -
All applicants must complete this section.
1. Has the Vermont Department of Taxes required a bond for this business entity or any business
Yes*
No
entity in which any person listed in Part 1 was an officer or held a 20% or more interest?
2. Has the Vermont Department of Taxes suspended or revoked a Sales and Use or Meals and
Rooms Tax license for this business entity or any business entity in which any person listed in
Yes*
No
Part 1 was an officer or held a 20% or more interest?
3. Have you previously had a principal interest in a business with a Vermont Business Tax account?
Yes*
No
*If any answer in Part 3 is “Yes”, please attach explanation.
PART 5 - CERTIFICATION -
All applicants must complete this section.
I certify under pains and penalty of perjury this application is true, correct and complete to the best of my knowledge.
Signature _________________________________________________
Title ___________________________________
Name ____________________________________________________
Date ___________________________________
(Please print)
Additional Information / Comments
Please allow two weeks for processing. If you need expedited processing, please contact us.
Send or fax completed application to:
Questions? Contact us by:
Vermont Department of Taxes
PO Box 547
Telephone: (802) 828-2551, option #3
Montpelier, VT 05601-0547
Email:
tax.business@vermont.gov
Fax: (802) 828-5787
Form BR-400 (formerly Form S-1)
Page 3 of 3
Rev. 08/15
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