Ets Form 001vd - Voluntary Disclosure Page 5
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Wyoming Department of Revenue
Excise Tax Division
122 W. 25th Street, Herschler Bldg.
Cheyenne, Wyoming 82002-0110
Voluntary Disclosure
1. Application Date:__________________________________________________________________________________
2. Ownership Name:______________________________________________(1)_________________________________
( federal identification number)
3. DBA/Doing business as:________________________________________(1)__________________________________
(
date and state of incorporation)
4. Please check one of the followng to best describe your ownership:
A._____Association/Club
B.______Corporation C.______Individual D.______Limited Partnership
E.______Limited Liability Company F.______Partnership G.______Other (explain)
5. Mailing Address: _________________________________________________________________________________
Street or Box No.
City
State
Zip Code
Location Address: _________________________________________________________________________________
6.
Street
City
State
Zip Code
7. Internet E-mail Address________________@___________________________________________________________
8. Business Telephone Number: (
)_____-___________ (800)______-___________Fax No.(
)______-___________
9. Authorized contact ____________________________________________________________(
)____-____________
Name
Phone number
10. What type of sales does this business make? Wholesale_______Retail________Services_______Maunfacturer_______
11. Estimated monthly sales volume: $_________________________________ ___________________________________
12. Describe specifically the type of products you sell, (Examples: auto parts, computers, vitamins) and/or services you
provide, (Examples: auto repair, computer repair) and the percent of the total sales each type represents [Example:
(must equal 100%) motel 50%, restaurant 30%, bar 20%]
(A)________________________
______%
(B)________________________
______%
(C)________________________
______%
(D)________________________
______%
13. Is this business located within the boundaries of an incorporated city or town in Wyoming?
Yes
No
14. Does this company have a physical location in this state?
Yes
No
15. Does your company make deliveries into this state with your own vehicles?
Yes
No
16. Do you extend or arrange for the extension of consumer credit?
Yes
No
17. Do you have employees, sales representatives, or other agents working temporarily or
Yes
No
permanently in the State?
Note: Corporations, limited partnerships, and limited liability companies must provide evidence of registration with
the Wyoming Secretary of State's Office (307) 777-7311). Corporations must attach a complete list of officers.
Limited liability companies must attach a complete list of members or managers. Licensing will be delayed
until this information is provided.
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