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ST VDA
Prescribed 4/11
Request for Sales or Use Tax Voluntary Disclosure Agreement (VDA)
A taxpayer is not required to reveal its identity in order to request a VDA. A representative may submit an anonymous re-
quest on the taxpayer's behalf. Alternately, a taxpayer may initiate its own request and provide the company name and other
information on the appropriate lines
Representative name _____________________________________________________________________________
Representative address ___________________________________________________________________________
City _____________________________________ State ___________________ ZIP code _________________
Email ____________________________ Telephone _______________________ Fax __________________________
Company name _____________________________________________________________________________
Company address _____________________________________________________________________________
City _____________________________________ State ___________________ ZIP code _________________
Email Telephone ______________________ Fax __________________________
Type of VDA requested (check all that apply):
Sales tax Consumer's use tax Seller's use tax (out-of-state sellers only)
Type of business ______________________________________________________________________________
Type of products or services sold in Ohio _____________________________________________________________
Method of marketing products or services in Ohio _______________________________________________________
Any other nexus-creating activities in Ohio ____________________________________________________________
Date activities began in Ohio ________________ Has sales tax been collected? Yes No
If already registered for sales or use tax, provide registration number _______________________________________
Estimated sales tax liability _________________________ Estimated use tax liability __________________________
Do you have a direct pay or have you held a direct pay within the last 4 years?*
Yes No
If so, do you have an ability make a claim (or have made a claim) against the State of Ohio based on amounts erroneously
paid to your vendors?
*The Department is not concerned about valid use based exemptions.
Yes No
Has the company been contacted by the Ohio Department of Taxation regarding a sales or use tax audit, enforcement ac-
tion or otherwise?
Yes No
If yes, please describe nature of contact by the department _______________________________________________
