EFTA02713564

1. MAIL & FAX YOUR TAX CLEARANCE APPLICATION AND NOTARIZED AFFIDAVIT TO VIIRB EITHER ADDRESS ON THE FRONT OF THE APPLICATION. 2. BE SURE TO NOTE WHICH ADDRESS YOU SEND IT TO AND KEEP A COPY FOR YOUR FILE. 3. ONCE YOU RECEIVE THE TAX CLEARANCE LETTER, MAIL IT ALONG WITH YOUR REGISTRATION APPLICATION, FEE AND PROOF OF MALPRACTICE INSURANCE TO THE BOARD OFFICE AT: PROFESSIONAL LICENSURE & HEALTH PLANNING VI DEPT. OF HEALTH 1303 HOSPITAL GROUND SUITE 10 ST THOMAS, VI 00802 4. IF YOU ARE NOT CURRENTLY WORKING IN THE USVI, PLEASE ATTACH A LETTER STATING SO. 5. DO Ti Ti MAIL YOUR TAX CLEARANCE APPLICATION TO THE BOARD OFFICE. 6. FAILURE TO FOLLOW INSTRUCTIONS WILL DELAY PROCESSING AS INCOMPLETE REGISTRATIONS WILL BE RETURNED TO YOU BY MAIL. 7. IF YOU HAVE ANY QUESTIONS PLEASE CALL: • MS GEORGE AT 340-774-7477 XT 5074 OR • MS RICHARDSON-PETER AT 340-773-1311 XT 3047. EFTA_R1_02135684 EFTA02713564 INSTRUCTIONS FOR FORMS LIC I AND LIC IA Please print (except for the signature). Do not write with a pencil. Prepare this form in duplicate. Have one of the copies stamped for your record. Save this copy for future reference. DO NOT SUBMIT A COPY OF THIS APPLICATION TO THE AGENCY REQUIRING THE CLEARANCE LETTER. This form must be completed in its entirety before a letter certifying tax filing and payment status can be issued. You are required to complete and submit a notarized affidavit (Form LIC IA) if you have not resided in the U.S. Virgin islands and have not filed your Federal Income Tax Returns for the three years prior to this application with the Bureau, if you have been unemployed for the past three years or if you were attending school. CORPORATIONS AND PARATNERSHIPS — List name, social security number and mailing address for corporate officers or partners. S CORPORATIONS — Also list name, social security number, and mailing address for all shareholders. ALL INCOMPLETE APPLICATIONS WILL BE REJECTED. Specific Instructions I. Line I - Name: The name under which the business is conducted; it may be the same as or different to the applicant's name (i.e. john Smith DBA Smith's Construction) 2. Line 2 - Tax Identification Number: 9-digit Employer Identification Number (EN) issued by the Internal Revenue Service (IRS) in Philadelphia to partnerships, corporations and self- employed individuals who pay wages to one or more employees, or 9-digit Social Security Number (SSN) issued by the Social Security Administration. 3. Line 3 - Type of Business: What service does your business perform (i.e. Lottery Dealer. Taxi Driver) 4. Line 9 — Mailing Address: Please be sure to provide the Bureau with your current mailing address. 5. Line 13 — Contact Number: Daytime number where you may be contacted. FORM UC1 (REV 07/2012) EFTA_R1_02135685 EFTA02713565 GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES 0 VIRGIN ISLANDS BUREAU OF INTERNAL REVENUE 6115 Estate Smith Bay - Suite 225 St. Thomas VI 00802 Phone: (340)715-1040 Fax: (340)714-9341 4008 Estate Diamond Plot 7B Christiansted VI 00820-4421 Phone: (340)773-1040 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. I. Name: 2. Tax Identification Number: 3. Type of Business: 4. Agency Requiring Report: 5. Please Indicate: K New License K License Renewal 6. Do you have employees? K Yes K No 7. Please indicate forms that you use: ❑1040/8689; ❑1065; ❑1120; 0941VI; ❑720V1; ❑720B; ❑722V1; ❑Other (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) EFTA R1 02135686 EFTA02713566 FORM t.IC in AFFIDAVIT UNITED STATES VIRGIN ISLANDS SSN: ST. CROLX, ST. THOMAS & JOIEN I say: after first being duly sworn, hereby depose and I. That Earn a resident of 2. That during the period from to I have been residing in and have filed my Federal Income Tax Returns with and paid any taxes due to the United States Federal Government at the Internal Revenue Service office in and to the State of or 3. That during the period from to I have been residing in and I was unemployed or did not have sufficient income to file an income tax return (mark out which one does not apply). If I was a full or part-time student, I attended Signature Subscribed and Sworn before me on this _ day of NOTARY PUBLIC EFTA_R1_02135687 EFTA02713567