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State of Arkansas
SALES AND USE TAX PERMIT
CITY OF BATESVILLE SOLID WASTE DATE ISSUED: 05/19/2007
SOO E MAIN STREET
BATESVILLE AR 72501 PERMIT NUMBER: 021776-78-002
DLN: 0000 00 0000 00000 00
OWNERI: DENISE M JOHNSTON DATE OPENED: 05/01/2007
OWNER2: ORVILLE R ELUMBAUGH
OWNER3:
OWNER4:
NAICS: 562998
All Other Miscellaneous Waste Management Services
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THIS BUSINESS IS EXEMPT FROM SALES TAX ONLY FOR THE PURCHASES OF GOODS
TO BE RESOLD IN THE NORMAL COURSE OF BUSINESS.
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THIS PERMIT IS VALID UNTIL IT IS CANCELED AND SURRENDERED BY THE PERMIT HOLDER OR
REVOKED BY THE COMMISSIONER OF REVENUES.
THIS PERMIT MUST BE SURRENDERED IF BUSINESS IS SOLD, DISCONTINUED OR LOCATION CHANGED.
WHEN THIS PERMIT IS SURRENDERED FOR ANY OF THE ABOVE REASONS, YOU MUST REPORT AND PAY
ANY SALES OR USE TAX PLUS ANY PENALTIES OR INTEREST THAT IS OWED BY THIS BUSINESS.
FAILURE TO PAY THESE TAXES WILL RESULT IN A LIEN BEING PLACED AGAINST THE STOCK AND
FIXTURES OF THIS BUSINESS AND IS ENFORCEABLE AGAINST PURCHASERS AND THIRD PARTIES.
PERMIT MUST BE DISPLAYED IN A PROMINENT PLACE IN YOUR BUSINESS
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V ARKANSAS
Department of Finance and Administration
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Sales and Use Tax Section
P. O. Box 1272, Little Rock, AR 72203-1272 (501) 682-7104
For Office Use
Application for Sales and Use Tax Permit
Applicants must answer ALL of the requested information fields in order to receive a permit for business in Arkansas.
1 • Q -Q �D CgtpplQt �fo-rm i BLUE or BLACK ink ONLY
1.
Na usiness BA)2.
Co orate Name or Partnership Name
3. 00 e `l\Cc*,n .L-br:e f—
Location - Street Address of Business (Not P. O. Box)
4.
Lo ation - Street Address of Business (if additional space is needed) !-
5. P- u �� -7a. &D '�'
City ST Zip Code County (if qn Arkansas)
6. � -� o - G9 ?-a *aD
Business Location Phone Number Ext
Mailing Address (if different from Location Address)
8.
Mailing Address (if additional space is needed)
9.
City ST Zip Code
10.
Owner/Home Office Phone Number Ext
11. I I K Ouc t04o
Federal I ,(I L�
Nam of er/Officer oPartner First MI Last
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Title r
Do L� .
Mailing Address of Owner
Maili g Address of gwner
City ST Zip Code SSN
13. Orv, a-,
Name of Owner/Officer or Partner First Last
L��o,�.a or
Title
0 e . I Yea;n
Mailing Address of Owner
Mail ng Address o Owner
City ST Zip Code SS
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14. List exactly the products sold or type of service rendered. U'( 9OU-t' t-'0- e- c-'+�U,
Form ST-1 (R 07/2006)
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15 . What's the dollar value of your inventory?
16
17.
What's the dollar value of your fixtures and erniinment?
Date you will begin your business? QuS
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mm/dd/yyyy
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18. Check type of business: Retail Wholesale
CHECK TYPE OF BUSINESS ENTITY:
19. Corporation 7 S Corporation = Individual Partnership
LLC = LLP = Government
20. Date Arkansas Incorporated? I S— W `j 1
mm/dd/yyyy
21. Please check one: Inside city limits � Outside city limits
22. Does this business sell or serve beer? wine? KO liquor? tZ mixed drinks?LX— Private Club? N
If YES, please furnish the ABC number under which you are operating.
23. Does this business sell tobacco products? wo `/
24. Do you operate more than one business in �kansas? y Z5 If YES, please list all locations, names, addresses and permit
numbers on�separate schedule. Cr nun c PC"/ G 4 C- VS
1 ?r rr, f 4 00,:2 / 7) (o - � a -C� l '(f,
25. Did you purchase the inventory, fixtures or equipment of an established business? � If YES, give the name and permit
number of the business. (attach bill of sale)
Former business name Former business permit number
26. Are you leasing the property? 0-0— If YES, attach a copy of the lease agreement.
27. Do you operate a business in your home? AL If Yes, attach a copy of your city business license or furnish a statement that
this license is not required.
28. If you operate an out-of-state business; do you perform any type of repair or service within the state of Arkansas?
If YES, please list exactly the repair or service performed.
Important Information
A) A $50.00 FEE IS REQUIRED OF ALL ARKANSAS VENDORS ON A RETAIL OR WHOLESALE BASIS.
Out of state vendors that lease property into Arkansas or perform taxable services in Arkansas are required to pay
the $50 registration fee. Please make check payable to Department of Finance and Administration.
B) The former owner of a business must surrender the permit, and report and pay all taxes due by the business through the transfer date. A lien will attach
to the stock and fixtures to secure the State of Arkansas for delinquent taxes and is enforceable against purchaser.
C) Arkansas Code Annotated 26-52-207 states that the tax liability of the former owner transfers to the new owner when the business is sold. No permit
will be issued to the new owner until all tax liability is paid.
I DECLARE UNDER PENALTY OF PERJURY, THAT THIS APPLICATION (INCLUDING ANY ACCOMPANYING SCHEDULES) HAS
BEEN EXAMINED BY ME, AND TO THE BEST OF MY KNOWLEDGE AND BELIEF IS A TRUE, CORRECT AND COMPLETE
AP LICATION.
Original Signature of O er/Partner/Officer Printed Name of Owner/Partner/Officer Date
FOR OFFICE USE ONLY - DO NOT WRITE IN THIS SPACE
SALES = USE = MD = LE
ACCT:
BONDED:
ISSUED BY:
COUNTY CODE
AV = TEX SIC:
LOC CODE: PREVIOUS ACCT:
DATE: PAID BY:
cash/check/money order
Form ST-f (R 07/2006)