Form Bc-100 - Indiana Business Tax Closure Request

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Indiana Department of Revenue
BC-100
Indiana Business Tax Closure Request
State Form 52038
TID Number: ______________________
Location(s) Number: _______
______
_______
(R7 / 7-12)
FID Number: ______________________
Tax Type:
Sales
Withholding
FAB
Other: _______________
Owner Name:
Social Security Number:
Corporation Name:
Address:
City:
State:
Zip:
I certify that I have been out of business or no longer required to be registered for the indicated tax type:
___________________
_____________
___________________
_____________
___________________
_____________
Type
Date
Type
Date
Type
Date
I further certify no tax of the above listed nature has been collected since the above date.
I may also be responsible for all liabilities or unfi led returns proven to be due and owed at a later date.
Printed Name:
Title:
Date:
Signature:
Daytime Telephone Number:
The Department will neither accept, nor process a BC-100 without proper documentation, attached to this form, proving the
business is closed.* Examples of documents the Department will consider acceptable include the following:
• Minutes of the fi nal board of directors meeting
• Final utility bills
• Records of bank accounts closed
• Any proof of dissolution fi led with the Internal Revenue Service
• Articles of dissolution
• Books and records or any other pertinent information
• Notarized statement of dissolution from an offi cer or owner of
the business
Note: This agency is requesting this disclosure of your social security number in accordance with IC 4-1-8-1.
Questions regarding the completion of this form may be directed to the Indiana Department of Revenue at (317) 233-4015.
Mail the completed form with documentation to:
Fax the completed form with documentation to:
Indiana Department of Revenue
(317) 615-2690
Tax Administration Processing
P.O. Box 6197
Indianapolis, IN 46206-6197
*The Department of Revenue prefers the above requested documents be submitted. However, if none of the requested documents are
available, the Department will accept this form signed by an offi cer or owner with a notary seal.

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