Indiana Indiana Business Closure Request

Indiana Business Closure Request	
Form BC-100
Indiana Department of Revenue

BC-100

Indiana Business Tax Closure Request

State Form 52038
(R13 / 6-21)

TID Number: _____________________

Location Number: ______________

FID Number: _____________________

Owner Name

Corporation Name

Address
City

State

ZIP

I certify that I have been out of business or I am no longer required to be registered for the indicated tax type.
I understand that I (or another responsible officer if applicable) am required to file and remit a tax return for the tax account(s) and tax
period(s) up to and including the closed date.

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Sales _______________
Date

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Withholding _______________
Date

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FAB _______________
Date

Other ____________________ ________________
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.
Signature:___________________________________	Date:____________________
Printed Name:________________________ 	Title:__________________	

Daytime Telephone Number:____________________

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This is a change of legal mailing address for the above listed closed tax account. Please forward any final correspondence
regarding this account to the following address:
Address
City, State and ZIP Code

Questions regarding the completion of this form may be directed to the Indiana Department of Revenue at (317) 232-2240.
Mail the completed form:	
Indiana Department of Revenue	
Tax Administration Processing
P.O. Box 6197	
Indianapolis, IN 46206-6197	

Fax the completed form:
(317) 232-1021
Complete the form online:
INTIME.dor.in.gov