Business Closure Form
Use this form only if a business operating in the Town of Occoquan has stopped operations permanently or moved out of the Town of Occoquan to a different jurisdiction. A separate form is needed for each closed location. Filing this form does not fulfill your obligation to also file any and all applicable documentation with Prince William County and the Commonwealth of Virginia about the closure of your business.
Filer Information
Business Trade Name
*
Business Entity Name
*
Business Location Type:
*
Commercial
Home Based
Closure Date in Town of Occoquan
*
-
Month
-
Day
Year
Date Picker Icon
Start Date in Town of Occoquan
*
-
Month
-
Day
Year
Date Picker Icon
Federal I.D. Number (or Social Security Number, if sole proprietorship)
*
Providing a Social Security Number is voluntary. The Town uses SSN’s for the Set-off Debt Collection Act, Va. Code § 58.1-521.
Business Email
*
example@example.com
Business Phone Number
*
Please enter a valid phone number.
Business Owner's Name and Title
*
General Partner Name:
If the business is organized as a limited partnership, name the general partner
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Forwarding Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for Closure:
*
Ceased all business activities across all locations
Sold business
Closed location in Town of Occoquan
Relocated business to location outside of Town of Occoquan
Other
Number of Full-Time Employees Prior to Relocation/Closure:
*
For economic development data reporting
Comments:
Signature
*
It is a Class 1 misdemeanor for any person to intentionally submit an application that they do not believe to be true and correct as to every material matter (VA Code §58.1-11). Businesses are subject to audit by the Town of Occoquan pursuant to VA Code §58.1-3109. I hereby 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.
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