Form                         Indiana Department of Revenue                                    Voluntary Disclosure Office
                                                                                                  Indiana Department of Revenue
            VDA-1                        Voluntary Disclosure Request                          100 N. Senate Ave., IGCN Room N241
      State Form 56462
             (1-18)                                                                                       Indianapolis, Indiana 46204
                           Phone: (317) 233-6036 | FAX: (317) 234-5531 | Website:www.in.gov/dor

1.Customer Identification

□ Yes     □ No     Are you representating a taxpayer requesting Voluntary Disclosure?
Customer or Representative Name                                                Taxpayer FEIN or SSN

Contact Name                                                  Contact Title

Mailing Address                                               Telephone                        FAX

City                                              State       ZIP Code         Email Address

2. Type of Entity/Ownership

□ Sole Proprietor     □ Partnership     □ LLC-Taxed as a Partnership     □ LLC-Taxed as a Corporation     □ C-Corp

□ S-Corp     □ Other (describe):

3. Is customer reqistered with the Indiana Secretary of State?

□ Yes     □ No        If yes, year:

4. Has the customer been contacted by the Indiana Department of Revenue regarding this liability?

□ Yes     □ No

5. Does customer’s income tax end on December 31?

□ Yes     □ No        If no, enter the fiscal year end date:

6. Has customer filed any recent short period income tax returns?

□ Yes     □ No        If yes, specify period ends:

7. Voluntary Disclosure by Tax Type

Returns     □ Yes     □ No If yes, please list below.
Sales and Use Tax

□ Yes                      Date activity began in Indiana:

□ No, explain              □ Already filing     □ Exempt     □ Other, explain:
Franchise/Income Tax

□ Yes                      Date activity began in Indiana:

□ No, explain              □ Already filing      □ Protected by PL86-272      □ Other, explain:
Withholding Tax

□ Yes                      Date activity began in Indiana:

□ No, explain              □ Already filing     □ Exempt     □ Other, explain:

 Other Tax Type

 □ Yes                     Date activity began in Indiana:

 □ No

 8. Describe customer’s activity in Indiana.

 Years:

 9. List property (real, personal, tangible or intangible) owned or rented in Indiana.

 Years:

 10. Additional Information
  1. What is the approximate liability (by tax type) for each of the years? If unknown, please state.

  2. Has any Indiana tax been collected or withheld?
     □ Yes     □ No     If yes, what is the initial date of collection?
  3. Has sales tax been paid to a vendor in error for which a credit is being claimed?
     □ Yes     □ No

If extra space is needed anywhere on this form, please attach additional pages.

Preparer’s Signature:  _______________________________________         Date:  _____________________________________
                           (not required if emailed)                                                 (mm-dd-yyyy)