Business Closure Form

2. 
   COMMISSIONER OF THE REVENUE

   COUNTY OF HENRY

   PO BOX 1077

   COLLINSVILLE VA 24078-1077

   PHONE: (276) 634-4690

3. BUSINESS CLOSURE FORM
5. Please read the following carefully and call our office should you have any question before submitting the form.

   Use this form only if a business operating in Henry County has stopped operations permanently or moved out of Henry County to a different jurisdiction. A separate form is needed for each closed location. 

   If you have any questions please contact the Commissioner of the Revenue office at 276.634.4690.

9. BUSINESS INFORMATION
11. Legal Business Name*
13. Trade Name/Fictitious Name
15. SSN or FEIN Number*
16. Business Account Number*
17. Business End Date in Henry County*
    Business End Date in Henry County
19. Business Physical Address*
21. City*
22. State*
23. Zip Code*

25. *Note: Business closed after January 1 of any year will be assessed for that year

29. OWNER INFORMATION
31. First Name*
32. Last Name*
34. Phone Number*
38. REASON FOR BUSINESS CLOSURE

    1. Ceased all business activity - No longer conducts any business activity
    2. Sold Business - Enter New Owner Name and Address Below
    3. Closed Location - Business No longer in Henry County
    4. New Mailing Address - Enter new address in the field below
40. New Owner Name
42. New Owner Address
44. New Mailing Address - Enter if checked above
46. Other (Please specify)
50. STATUS OF BUSINESS ASSETS

    1. Disposed of property
    2. Converted to personal use
    3. Sold
    4. Moved with Business Relocation
    5. Assets Sold with Business*
52. Access to Asset List

    *If business was sold, the new owner has to report assets based onthe original cost and purchase date. Do you give permission to share your most recent asset list with the new owner? 

    1. Yes
    2. No
54. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) you are allowing the release of your asset list, and 2) you may still be required to provide a traditional signature at a later date.

    *NOTE: If you checked "Yes" to share your most recent asset list with the new owner but did not check "I agree" and enter your initials then the asset list WILL NOT be shared with the new owner.

    1. I agree.
56. Electronic Signature

    *Please note that closing a business may not exclude you from paying Business Tangible Property tax for the current year.

60. Electronic Signature Agreement - Business Closure Certification*

    I herby certify that I am not conducting any business at the above business location address and declare under penalty and perjury, that I am authorized to complete this application. To the best of my knowledge and belief, the provided information is true and correct.

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
64. FOR OFFICE USE ONLY:
66. Date Received
    Date Received
67. Additional follow up required?

    1. Yes
    2. No
69. Notes:
71. Processed by:
72. Date:
    Date:
Leave This Blank:


74. Submit

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