Commissioner of the Revenue                                              202 4HENRY COUNTY LICENSE
             PO Box 1077                                                              This form must be filed with the Commissioner of 
             Collinsville, VA 24078-1077                                              the Revenue and the tax paid on or before March 1. 
             (276) 634-4690
                                                                                      Make checks payable to Treasurer of Henry County

                                                                                      Trade Name and Henry County Location

                                                                                      Account #:

For period beginning January 1, 202 4 and ending December 31, 202 4
Check one:   Individual         Partnership          Corporation             LLC
Sales Tax #_________________________

CODE         LICENSEE APPLIES FOR THE FOLLOWING RENEWAL                                          GROSS                    TAX 
             See reverse for additional instructions                                             RECEIPTS 

If you are no longer in business, please provide the date closed:__________________             Taxes prescribed by law $__________
                                                                                                 Penalties $__________
Contractor licenses can't be renewed or issued without a valid copy of State License       Total taxes and penalties $__________
and a completed Workers Compensation Certification (Form 61-A) verifying 
Workers Compensation.
I, the undersigned, declare under penalty of the law that I have examined this return           THIS LICENSE EXPIRES                                       PLEASE DISPLAY THIS PROTION OF LICENSE
and to the best of my knowledge and belief, it is a true, correct, and complete form.
                                                                                                12/31/24
SIGN HERE _______________________________________________________
                                Your Signature and Title                              LICENSE NOT VALID UNLESS STAMPED 
                                                                                      BY COUNTY TREASURER’S OFFICE 
_____________________________________            ____________________
             Print Name                                       Date

PHONE    (______) ____________________________

EMAIL     _____________________________________
                                                                                      BY____________________________ 
If not a Virginia Corporation, please provide date of qualification in Virginia.

__________________   ________________________________________
    Date                          Commissioner of the Revenue Deputy or Clerk

Note: It is a Class 1 Misdemeanor for any person willfully to subscribe a return which he does not believe to be true and correct as to every material matter (Code of VA. 
Sec. 58.1-11)

                   INSTRUCTIONS FOR COUNTY BUSINESSES 

FILL IN INFORMATION AND RETURN WITH PAYMENT TO COMMISSIONER OF REVENUE. YOUR 
COPY WILL BE RETURNED TO YOU. APPLICATION BECOMES VALID LICENSE WHEN STAMPED BY 
THE COUNTY TREASURER'S OFFICE. 

DOCUMENTATION REQUIRED: EACH BUSINESS IN CATEGORIES 1-5 AND 8 MUST SUBMIT A COPY 
OF ITS BUSINESS SCHEDULE CORP & L STATEMENT WITH ITS BUSINESS LICENSE APPLICATION. 

(The following information is taken from the Business, Professional, and Occupational License 
Ordinance adopted by the Henry County Board of Supervisors. For a complete copy of the 
Ordinance, contact the County Administrator's Office, County Administration Building.) 

TAX RATES: The following are annual tax rates under this Ordinance: 

For code/category  thru1 5, businesses with gross receipts of less than $100,000.00, there will be an annual fee 
of $30.00. 

Code/Category 1:                       Contractors: .00025 of gross receipts. (Minimum License $30.00) 
Code/Category 2:                       Retail Sales: .0015 of gross receipts. 
Code/Category 3:                       Financial, Real Estate, and Professional Services: 
                                       .0025 of gross receipts 
Code/Category 4:                       Repair, Personal, and Business Services and Other Businesses: 
                                       .0015 of gross receipts. 
Code/Category 5:                       Wholesale Sales: .0005 of purchases.    
Code/Category 6:                       Carnival, Circus, etc.: $500.00 per day (may be waived for 
                                       non-profit organizations). 
Code/Category 7:                       Fortune-Tellers, Clairvoyants, and Practitioners of Palmistry 
                                       or Phrenology: $500.00 annually. 
Code/Category 8:                       Utilities: .005 of gross receipts, not including any charges for 
                                       long-distance telephone calls. 
Code/Category 9:                       Itinerant Merchants: $500.00 annually. 
Code/Category 10:                      Peddlers: $50.00 anually. 

BASIS FOR ASSESSING TAX: The above rates in Categories 1-5 and 8 will be applied against the gross receipts 
of the business in the prior calendar year. If the business files its income tax returns on a fiscal year basis, the tax 
may be paid for the most recent fiscal year ending in the prior calendar year. 

NEW BUSINESSES: Before beginning operations, a new business must obtain a business license. If in 
Categories 1-4, the tax will be assessed on estimated gross receipts for the remainder of the current calendar 
year. An adjustment to actual gross receipts will be made in the following year. 

BUSINESS FALLING IN MORE THAN ONE CATEGORY: If a business operates in more than one of the above 
categories, a license must be obtained in each category and documentation on the breakdown of gross receipts 
by category (If applicable) must be provided. At its option, such a business may choose to pay all its tax in the 
category with the higher rate. 

TERM OF LICENSE: All business licenses are issued annually. Application for license may be made from January 
1 to March 1; the fee must be paid by March 1 to avoid penalty. 

PENALTY: A penalty of 10% per year will be added to all license taxes not paid by March 1. It shall be unlawful 
AND a Class 3 misdemeanor to operate or conduct a business without first obtaining a license.