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2. Margaret S. Torrence
   Commissioner of Revenue
   Franklin County, Virginia
   1255 Franklin St., Suite 102
   Rocky Mount, VA 24151
   Phone: (540) 483-3083
   Fax: (540) 483-3089
4. Business Name*
6. Is the business permanently closed?*

   1. Yes
   2. No
7. Closed Date*
   Closed Date
9. Did the business move to another locality?*

   1. Yes
   2. No
10. What date did you move your business?*
    What date did you move your business?
11. If moved in Virginia, which locality?
12. If moved out of state, which state?
14. If moved, provide New Address*
    Enter your new physical business address
16. City*
17. State*
18. Zip Code*
22. STATUS OF ASSETS
24. Disposed of Assets?*

    1. Yes
    2. No
25. Disposal Date*
    Disposal Date
26. Personal Use?*

    1. Yes
    2. No
27. Change Date*
    Change Date
29. Sold?*

    1. Yes
    2. No
30. Sold Date*
    Sold Date
34. CONTACT INFORMATION
36. Name*
37. Phone*
38. Email
40. New Mailig Address (if applicable)
42. City
43. State
44. Zip Code
46. Electronic Signature Agreement*

    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.
48. Electronic Signature
49. Title
50. Date
    Date
52. IMPORTANT MESSAGE: The Commissioner of Revenue office will contact you to obtain additional information needed to process this request.
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

* indicates a required field