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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 Contractor Receipts by Jurisdiction Business Information Name Account # Contractor's License # Tax Year Gross Receipts Report Job Jurisdiction Town/City County State Job Gross Receipts Job Duration Over 30 Days? Certification By signing, I certify that I am authorized to file this form and the information provided herein is true and correct. Title/Role Signature Date Authorized Signer Name 1 I BTA6-0625 (choose one) (choose one) (choose one) (choose one) (choose one) (choose one) (choose one) (choose one) (choose one) (choose one) (choose one) (choose one) (choose one) (choose one) SIGN ---PAGE BREAK--- Contractor Receipts by Jurisdiction General Information Virginia law requires contractors to file their gross receipts by job and the duration of the job. This information is used by the Commissioner of the Revenue to calculate the business's tax liability. Review relevant info at . Use this form to file contractor receipts by jurisdiction. Need help? Staff assistance is available Monday through Friday, during County business hours. To reduce your wait time, we encourage scheduling an appointment. We are open 8:30 AM to 5:00 PM in: loudoun.gov/BusinessTax Leesburg Sterling 1 Harrison St. SE, 1st Floor 46000 Center Oak Plaza For assistance with a specific topic, email or call: Business Tax Assessment [EMAIL REDACTED] [PHONE REDACTED], option 2 Accommodations: If you require a reasonable accommodation for any type of disability or need language assistance in order to access this form, please contact [EMAIL REDACTED]. Three business days 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 1. Business Information - Provide the business name, account number, license number, and the applicable tax year for the gross receipts listed below. 2. Gross Receipts Report - List the town or city, county, and state in which each job was performed. Provide the gross receipts for the job and the duration (in days) that the job took to complete (from start to finish). 3. Certification - Review and complete the certification, including indicating the authorized signer name and title or role in the business. 4. Submit this form in-person at one of the locations listed above or: Upload it to: loudoun.gov/COR-Upload Mail it to: Business Tax Assessment 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 BTA6-0625