State Form 10763 (R4/9-10) Fiscal content SBA Approved - 1982 Indiana Department of Revenue Official Use Only Aircraft Dealer Registration Application  Check One: New Dealer Application  Dealer Reg. No. Aircraft Dealer Renewal Approved  Denied  If Renewal Enter Dealer Number Indiana Retail Merchant’s Number (Must obtain BEFORE applying) Federal I.D. Number Owner name, Legal name, Partnership name, Corporate name or Other entity name -- If sole owner (Last name, First name, Middle Initial) Business Trade Name or Doing Business as (DBA) Name Street Mailing Address #1 Street Mailing Address #2 City State Zip Code 1. Check the type of organization of this Business:  Sole Owner  Partnership  Corporation  Other (Specify) ______________________ 2. All corporations please answer the following questions: A. State of Incorporation ______________________________ B. Date of Incorporation ______________________________ C. State of Commercial Domicile________________________ D. If not incorporated in Indiana enter the date authorized to do business in Indiana _____/_____/____. (Month / Day / Year) E. Accounting period year ending date: ______/______ (Month / Day) 3. Name(s) of owners, partners, or officers: Name: Name: Name: Title: Title: Title: Address: Address: Address: City: State: Zip Code: City: State: Zip Code: City: Social Security Number: Social Security Number: State: Zip Code: Social Security Number: Attach additional sheets if necessary 4. Name of Contact Person 5. Contact Daytime Telephone Number: 6. Name of Airport of Operation 7. County (of Airport location) 8. Established place of business: A. Office located at airport Yes No Office located at residence Yes No     Office located at other facility Yes No Specify other facility location   B. Place of Business has exterior sign identifying dealer by name  Yes  No C. Advertised as aircraft dealer in the following 1. Telephone Book Yes No Email Address   2. Internet Yes No   3. Other Yes No Specify:   D. Insured or bonded as commercial business in aircraft sales Yes No   Turn the Page American LegalNet, Inc. www.FormsWorkFlow.com 9. Calendar Year Applying for a Dealer Registration _____________________________ (If applying in December, you may indicate the next calendar year) 10. Twenty-five dollar ($25) non-refundable registration processing fee must be submitted with this application made payable to : Indiana Department of Revenue. 11. All aircraft dealer renewals must complete the following information for the past eleven (11) month period. If you have been an aircraft dealer for less than eleven months indicate time period being reported. A. B. C. D. / Time Period from Month / Year In state aircraft sales 1. Total number of taxable aircraft sold in Indiana 2. Total dollar amount of taxable sales in Indiana 3. Total number of aircraft sold in Indiana as exempt purchases 4. Total dollar number amount of exempt aircraft sales Out of state aircraft sales 1. Total Number of aircraft sold out of Indiana 2. Total Dollar amount of aircraft sold out of Indiana Inventory aircraft 1. Number of aircraft currently held in inventory for resale 2. Number of aircraft currently being used for non-dealer use Total income reported from aircraft sales on last income tax return to / Month / Year $ $ $ $ Common Reasons for Denial The following list contains the most common reasons that an application may be rejected. Please note your $25.00 registration processing fee is non-refundable if your application is rejected or denied. 1. Incomplete application submitted. (Example: Indiana Registered Retail Merchant number “applied for” or left blank) 2. Incorrect information submitted. (Example: Federal ID Number not assigned to the entity name on the application) 3. Entity has any outstanding liabilities for any tax type that is not paid or satisfied. 4. Entity has any missing tax returns for any tax types and does not provide copies upon request. Signature Section Under penalty of perjury, I certify that the above information contained herein is to the best of my knowledge true and correct. Signature Title Name (Printed) Date This application must be signed by the owner, general partner or corporate officer before it will be accepted by the Department. NOTE: Failure to remit sales tax due is punishable by imprisonment, a fine of $10,000 plus a 100% fraud penalty. The partners or corporate officers are each personally, jointly and severally liable for the sales and use tax collected. These taxes are trust fund taxes and are not discharged in bankruptcy proceedings. Mail To: Please direct any questions to (317) 615-2544. Indiana Department of Revenue Special Tax – Aeronautics P. O. Box 644 Indianapolis, IN 46206-0644 American LegalNet, Inc. www.FormsWorkFlow.com