Indiana Department of Revenue BC-100 State Form 52038 (R6 / 12-10) Indiana Business Tax Closure Request TID Number: ______________________ Tax Type: □ Sales □ Withholding FID Number: ________________________ □ FAB Owner Name: □ Other: _______________ 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 unfiled 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 final board of directors meeting. Records of bank accounts closed. Articles of dissolution. Notarized statement of dissolution from an officer or owner of the business. • Final utility bills. • Any proof of dissolution filed with the Internal Revenue Service. • Books and records or any other pertinent information. 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 Tax Administration Processing P.O. Box 6197 Indianapolis, IN 46206-6197 (317) 615-2690 *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 officer or owner with a notary seal. American LegalNet, Inc. www.FormsWorkFlow.com