Mobile Business Information

For mobile businesses (e.g., food vendors, lawncare, contractors, etc.) that use a Department of Motor Vehicle-tagged “item” (e.g., vehicle, trailer, etc.)

1

Business Name:

 *

Business Name:

2

Current Frederick County Business License Account Number:

Current Frederick County Business License Account Number:

3

Name of Person Operating Business:

 *

Name of Person Operating Business:

4

Provide Either your Federal Employer I.D Number (FEIN) or your last four digits of your Social Security Number (SSN) below:

 *

Provide Either your Federal Employer I.D Number (FEIN) or your last four digits of your Social Security Number (SSN) below:

FEIN If other, type text here.

SSN If other, type text here.

5

Telephone No.:

 *

Telephone No.:

6

Email Address:

 *

Email Address:

7

Physical Street Address of Business:

 *

Physical Street Address of Business:

8

City:

 *

City:

9

State:

 *

State:

10

Zip Code:

 *

Zip Code:

11

Garage Location (County) of DMV-tagged “item” (e.g., vehicle) during non-business hours:

 *

Garage Location (County) of DMV-tagged “item” (e.g., vehicle) during non-business hours:

12

Make:

 *

Make:

13

Model:

 *

Model:

14

Year:

 *

Year:

15

Vehicle Identification Number:

 *

Vehicle Identification Number:

16

License Plate Number:

 *

License Plate Number:

17

Check One:

Check One:

Vehicle is leased (if so provide leasing company below) If other, type text here.

Vehicle is owned

If your vehicle is neither leased or owned, please explain: If other, type text here.

18

Purchase Price:

 *

Purchase Price:

19

Date Acquired (mm/dd/yyyy):

 *

Date Acquired (mm/dd/yyyy):

20

List the amenities that were included with the purchase of the vehicle (example: stove, refrigerator etc.):

List the amenities that were included with the purchase of the vehicle (example: stove, refrigerator etc.):

21

List the modifications/upgrades made to the vehicle after purchase and the cost of each (example: stove, refrigerator etc.):

	Modification Description	Modification Cost
Modification 1	List the modifications/upgrades made to the vehicle after purchase and the cost of each (example: stove, refrigerator etc.):	List the modifications/upgrades made to the vehicle after purchase and the cost of each (example: stove, refrigerator etc.):
Modification 2	List the modifications/upgrades made to the vehicle after purchase and the cost of each (example: stove, refrigerator etc.):	List the modifications/upgrades made to the vehicle after purchase and the cost of each (example: stove, refrigerator etc.):
Modification 3	List the modifications/upgrades made to the vehicle after purchase and the cost of each (example: stove, refrigerator etc.):	List the modifications/upgrades made to the vehicle after purchase and the cost of each (example: stove, refrigerator etc.):
Modification 4	List the modifications/upgrades made to the vehicle after purchase and the cost of each (example: stove, refrigerator etc.):	List the modifications/upgrades made to the vehicle after purchase and the cost of each (example: stove, refrigerator etc.):
Modification 5	List the modifications/upgrades made to the vehicle after purchase and the cost of each (example: stove, refrigerator etc.):	List the modifications/upgrades made to the vehicle after purchase and the cost of each (example: stove, refrigerator etc.):

The owner must sign/file this form.  If the business is an entity such as a trust, partnership, limited liability company, or corporation, it must be signed by a member, partner, executive officer, or other person specifically authorized in writing by the trust, partnership, limited liability company, or corporation to sign/file.

Declaration:  I hereby declare, under penalty of perjury, that the statements made herein are true, complete, and correct to the best of my knowledge and belief, and that I am the owner of the business or a member, partner, executive officer, or other person specifically authorized in writing to sign on behalf of the business.

 

In lieu of an actual signature, you must provide the following information below.

22

Your Name:

 *

Your Name:

23

Your title or capacity for signing/submitting on behalf of the Business (e.g., Owner, Vice-President):

 *

Your title or capacity for signing/submitting on behalf of the Business (e.g., Owner, Vice-President):

24

Today's Date (mm/dd/yyyy):

 *

Today's Date (mm/dd/yyyy):

*You must notify the Commissioner of the Revenue immediately upon selling the vehicle and/or purchasing any additional vehicle.

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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