GOVERNMENT OF

THE VIRGIN ISLANDS OF THE UNITED STATES



ae |



VIRGIN ISLANDS BUREAU OF INTERNAL REVENUE



6115 Estate Smith Bay - Suite 225 4008 Estate Diamond Plot 7B



St. Thomas VI 00802 Christiansted VI 00820-4421

Phone: (340) 715-1040 Phone: (340) 773-1040

Fax: (340) 714-9341 Fax: (340) 773-1006



APPLICATION FOR TAX FILING AND PAYMENT STATUS REPORT



The applicant identified below hereby requests a letter certifying his or her tax filing and payment status for the

purpose of receiving a new or renewal license from the Agency requiring the clearance letter. The applicant

authorizes the Virgin Islands Bureau of Internal Revenue to disclose any taxpayer information related to this

application to the below listed Agency, who may make such further disclosures as are necessary to the relevant

agency as required by the appropriate law.



1. Name: i 14 sos



2. Tax Identification Number:



3. Type of Business: | — = Eres



5. Please Indicate: [_] New License [_] License Renewal



6. Do you have employees? [_] Yes []No



7. Please indicate forms that you use: [[]1040/8689; [_]1065; (1120; (J941v1; (1720V1; [1720B;

[}722V1; [_Jother (please list)



8. Date Business Started: License Expiration Date:



9. Mailing Address (Required): —



10. Physical Address:



11. Contact Person (Please Print): _ =



12. Signature:



13. Date: Contact Number (Required):

REPLY TO THE ADDRESS OF THE RESPECTIVE DISTRICT LISTED ABOVE.



See Back Of Form For Instructions

FORM LIC 1 (REV 07/2012)