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Mailing Address PO Box 8000, Leesburg, VA 20177-9804 In-person Service Leesburg - 1 Harrison Street SE, 1st Floor Sterling - 46000 Center Oak Plaza Robert S. Wertz, Jr. Web loudoun.gov/COR Phone [PHONE REDACTED] Construction Contractor Affidavit General Information The Code of Virginia 54.1-1111) prohibits Loudoun County from issuing/renewing a business license unless the contractor has either provided their license or certification number issued by the State Board of Contractors, Virginia Department of Professional and Occupational Regulation (DPOR), or provided a written statement, supported by affidavit, that they are exempt from such licensure or certification. Review relevant info at: loudoun.gov/BusinessTax. Use this form to provide the written statement and affidavit for contractors not subject to DPOR certification or licensure. Need help? Please contact the DPOR at (804) 367-8511 or visit their website at dpor.virginia.gov, for questions concerning state contractor licensing requirements. Staff assistance is available from this Office Monday - Friday, 8:30 AM to 5:00 PM. To reduce your wait time, we encourage scheduling an appointment. Accommodations: To request language assistance or a reasonable accommodation for any type of disability to access this form, please contact [EMAIL REDACTED] or [PHONE REDACTED]/TTY-711. Advance notice is requested. Privacy: This Office protects records according to applicable Virginia statutes and U.S. federal laws. Any personal information we collect and maintain is retained in compliance with statute. Instructions Complete and sign before a notary. Submit this form in-person or: • Upload it online: loudoun.gov/COR-Upload • Mail it to: Business Tax Assessment PO Box 8000, Leesburg, VA 20177-9804 • Find webforms: loudoun.gov/TaxRelief-Forms Affidavit - To be signed before a Notary Public I, as of Full legal name Capacity: Title/Role Contractor/Subcontractor Business Name being the owner, or if business is an entity such as a trust, partnership, limited liability company or corporation, being a member, partner, executive officer, or other person specifically authorized in writing to sign on behalf of the above-named business, first being duly sworn, to hereby depose and state as follows: I am not and/or the above-named business is not subject to licensing or certification as a contractor or subcontractor pursuant to Chapter 54.1 of the Code of Virginia, as amended. I have read and understand relevant Virginia law, and unless qualifying for an exemption, will not perform or manage construction, removal, repair, or improvements where the individual contract or project value or annual aggregate value of all projects exceeds the amount permitted by law. I will retain a copy of this completed/signed Statement and Affidavit. Authorized Signature Date Notary Public - In the Commonwealth of Virginia, City/County of I certify that the above-named person, being first identified and duly sworn by me, affirmed that the statements given are true and correct. Subscribed and acknowledged before me on this SEAL day of 20 Notary Public Registration No. Commission Expires 1 I BTA10-1225 SIGN