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Robert S. Wertz, Jr. Web loudoun.gov/COR Phone [PHONE REDACTED] Mailing Address PO Box 8000, Leesburg, VA 20177-9804 In-person Service Leesburg - 1 Harrison Street SE, 1st Floor Sterling - 46000 Center Oak Plaza Domicile Certification Vehicle Owner Identification Full Legal Name (First, Middle, Last) Mailing Address SSN Driver's License Number State Issued Email Daytime Phone Vehicle Owner Residency Information Physical Address Do you own real estate in Loudoun County? [ ] No [ ] Yes If yes, list each address (number & street, city, zip): Address 1: Address 2: Address 3: Local Connection Information Do you file a state income tax return? [ ] No [ ] Yes If yes, in what state? Address listed on the State Income Tax Return Are you employed in the District of Columbia, Maryland, or Virginia? [ ] No [ ] Yes If yes, name and address of your employer: Do you have children attending Loudoun County public schools? [ ] No [ ] Yes Are you registered to vote? [ ] No [ ] Yes If yes, in what state? Date came to Loudoun County? Reason for coming? Activities primarily engaged in while in Loudoun? [ ] Employment [ ] Education [ ] Leisure [ ] Other Vehicle Information Vehicle Make Model Year License Plate Number License Plate State Title Number Vehicle Identification Number Percent of time vehicle is normally garaged/parked in Loudoun County? [ ] 0-24% [ ] 25-49% [ ] 50-74% [ ] 75-100% Certification I understand that the Commissioner of the Revenue will make a domiciliary determination using this information and other available sources. I believe that my domicile is the County/City/Town of I certify that the information contained on this document is complete and accurate. I agree to supply documentation related to this certification, if requested by the Commissioner of the Revenue. Date Signed Signature of Vehicle Owner 1 I PPA1-1125 SIGN ---PAGE BREAK--- Domicile Certification General Information Use this form to provide information that will be considered in determining your domicile for the purpose of taxing a specific vehicle. The Office of the Commissioner of the Revenue determines a person's "domicile" for local tax purposes. Your domicile is the present, fixed home where you return following temporary absences and where you intend to stay indefinitely. A person may only have one domicile at a time. Review relevant assessment information at: loudoun.gov/PersonalPropertyAssessment. Need help? Staff assistance is available Monday through Friday, during business hours. To reduce your wait time, we encourage scheduling an appointment. We are open 8:30 AM to 5:00 PM in: Leesburg Sterling 1 Harrison St. SE, 1st Floor 46000 Center Oak Plaza For assistance with a specific topic, email or call: Vehicle Personal Property [EMAIL REDACTED] [PHONE REDACTED], option 1 Accommodations: To request language assistance or a reasonable accommodation for any type of disability to access this form, please contact [EMAIL REDACTED] or 703-777-0260x1/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 Use one form for each vehicle. 1. Owner/Taxpayer Identification - Provide your name as it appears on legal documents such as your driver's license, identity card, or passport. Enter your current mailing address, social security number (SSN) or, if none, driver's license number and state where issued, your phone number and email address. 2. Owner/Taxpayer Residency Information - Answer each question, providing the physical location of your current residence and the address(es) of any other real estate you own in Loudoun County. 3. Local Connection Information - Answer each question, providing the state where income taxes are filed and address used for filing, employer's name and address, indicating whether you have children attending public school in Loudoun County, the date you came to Loudoun County, your reason for coming to Loudoun County, and activities you engage in while in Loudoun County. 4. Vehicle Information - Provide all the information requested to identify your vehicle. Estimate as accurately as possible what percentage of the time your vehicle is garaged or parked in Loudoun County. 5. Certification - The vehicle owner must read and sign the certification. 6. Submit this form in person at one of the locations listed above or: Upload it to: loudoun.gov/COR-Upload Mail it to: Vehicle Personal Property PO Box 8000, Leesburg VA 20177-9804 Find webforms at loudoun.gov/COR-Forms 2 I Loudoun County I Office of the Commissioner of the Revenue I PPA1-1125