Indiana Business Tax Clearance Form

Business Tax Clearance Form
Form 53227
Indiana Department of Revenue

State Form 53227
(R5 / 2-19)

Tax Clearance Form

Permit Number

Hearing Date

Expiration Date

1. Tax Identification Numbers
Federal ID Number (FID)

State Tax ID Number (TID)

2. Corporate, Partnership, or Sole Proprietor Information
Name

Phone Number

Mailing or Street Address
City

State

ZIP Code

County

3.Business Trade Name (DBA)
Name

Phone Number

Location Address
City

State

4. Nonprofit Information
Is this business registered as a nonprofit organization in Indiana?
5.Type of Ownership

□
□

Sole Proprietorship	
Partnership	

□
□

ZIP Code

□

Yes

□

Corporation (For Profit)	
Government	

□

No

County

If yes, what is your number?
_________________________

Other (Specify)

______________________________

6. All corporations, please complete the following information. All others, go to line 7.
State of Incorporation

Date of Incorporation

If not a corporation, enter date authorized to do business in Indiana.
7. Bankruptcy Information
Has this business entity ever filed bankruptcy?

□

Yes

□

State of Corporate Domicile
Accounting Period Year Ending Date (mm dd)

If so, when?
____________________________

No

I authorize the Department of Revenue to release the current tax information of the applicant named above to the Alcohol and Tobacco
Commission for the purpose of issuing an ABC Permit.
Authorized Signature:_________________________________ 	

Title:_________________________ 	

This clearance is valid for thirty days only.

Date:________________

To: Liquor Permit Applicants
From: Indiana Department Of Revenue
Subject:Tax Clearance Form
IC 7.1-3-21-15 (a) (3) the commission shall not issue, renew, or transfer a wholesaler, retailer, dealer, or other permit of
any type if the applicant is on the most recent tax warrant list supplied to the commission by the Department of State
Revenue.
To obtain such verification, applicants must file a completed Tax Clearance Form with the Department. Applicants must
provide all requested information. Failure to timely file a Tax Clearance form or provide all requested information may
result in delay or denial of your application.
Applicants may mail the completed Tax Clearance Form to Titles & Clearances Division 100 N. Senate Ave,
Indianapolis, IN 46204. Applicants may file the Tax Clearance Form in person at Room N-105, Indiana Government
Center North.
The Department of Revenue will provide information concerning tax liabilities of applicants to the Alcohol and Tobacco
Commission (ATC). ATC will provide verification of the applicant’s tax status to the local alcoholic beverage board.
For further information, call (317) 232-5977.
The original blue form must be completed, signed and returned for approval.
This clearance is valid for thirty days only.

Department Use Only
A/R __________________________________________

RST ____________________________________________

WTH _________________________________________

FAB _____________________________________________

CIT ___________________________________________

IND _____________________________________________

COR__________________________________________

NFP ____________________________________________

Employee______________________________________

Date ____________________________________________
Supervisor _______________________________________