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               State of Wisconsin                          l    DEPARTMENT OF REVENUE
                 NEXUS UNIT    l 2135 RIMROCK RD     MAILl STOP 3-107    POl BOX 8906     MADISONl WI  53708-8906     FAX (608)261-7049    l WEBSITE: lrevenue.wi.gov

                                                       Registration Verification

This form must be completed and returned to the department to document the tax status of your business. Failure to verify 
that your business, and all affiliates of your business, have a Wisconsin tax permit/certificate or that all sales are exempt, 
will mean that Wisconsin agencies and authorities are prohibited from purchasing products or services from you.

Legal name

Business name (DBA)

Mailing address

Federal ID number

Type of property sold

Type of services sold

Current Wisconsin Registration Status  (please check appropriate box)
We are currently registered to collect and remit Wisconsin sales and use tax.  Enter Wisconsin tax account number.

We are submitting a completed Application for Business Tax Registration (BTR-101) to register for the collection and 
remittance of Wisconsin sales and use tax.  Include the application with this form.

All of our sales are exempt sales of tangible personal property or services in Wisconsin. Complete an Affidavit of Exempt 
Sales (A-006) and return it with this Registration Verification form.

We no longer make any sales into the state of Wisconsin.

Affiliate Information  (please check appropriate box)

An “Affiliate” means a person or business that controls, is controlled by, or is under common control with another person or 
business. “Control” means to own, directly or indirectly, more than 10% of the interest in or voting securities of a business.

Do you have any affiliates selling tangible personal property or services in Wisconsin?                                                      Yes       No 
If Yes, complete and attach the Affiliate Registration Verification form (A-002) provided.

I certify that, to the best of my knowledge, the above information is accurate and complete.

Completed by  (please type or print)                                                      Title

Signature                                                                                 Date

Telephone Number                                                                          Fax Number

A-001 (R. 4-14)