Fillable NOTICE OF TAX PAYMENT DEFAULT (Virginia Department of Motor Vehicles)

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NOTICE OF TAX PAYMENT DEFAULT (Virginia Department of Motor Vehicles)

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FT 214 (10/25/2012)
Purpose: Supplier/providers use this form to report a licensed distributor/importer/bonded bulk user of alternative fuel
and/or a bonded retailer of alternative fuel who has failed to pay tax and tank fee owed.
Instructions: Completed form must be submitted within 10 business days from the date you are required to pay the tax to:
Tax Services, P.O. Box 27422, Richmond, VA, 23269-7422.
FAX NUMBER
TAX PAYMENT DUE DATE (mm/dd/yyyy)
FEIN/SOCIAL SECURITY NUMBER
VIRGINIA FUEL TAX
NOTICE OF TAX PAYMENT DEFAULT
SUPPLIER/PROVIDER INFORMATION
FULL LEGAL NAME (last) (first) (mi) (suffix) FEIN/SOCIAL SECURITY NUMBER
COMPANY NAME
TAX DEFAULT INFORMATION
AMOUNT OF TAX NOT PAID
$
IRS TERMINAL CONTROL NUMBER
CERTIFICATION
AUTHORIZED REPRESENTATIVE NAME (print) TITLE
AUTHORIZED REPRESENTATIVE SIGNATURE DATE (mm/dd/yyyy)
TELEPHONE NUMBER
EMAIL ADDRESS
I certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine,
and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under
penalty of perjury and I understand that knowingly making a false statement on this form is a criminal violation.
( )
( )
FT 214 (10/25/2012)
Company Name and FEIN/Social Security Number - of the licensed distributor/importer/bonded bulk user/bonded retailer who has
failed to pay tax owed.
Date Tax Payment Was Due - Month, day, and year that payment was due.
Amount of Tax Payment Not Paid - Total amount of tax that company has not paid.
Terminal Control Number - Of the terminal where the product was purchased.
FILING INFORMATION
A supplier/provider must submit this notice if a licensed distributor or importer fails to pay the tax owed. Providers of alternative fuel
must submit this notice if a bonded bulk user or bonded retailer of alternative fuel fails to pay the tax owed. This notice must be
submitted within 10 business days from the date the tax is due to DMV.
SUPPLIER/PROVIDER INFORMATION
Name and FEIN/Social Security Number - of the supplier/provider reporting the default in payment.
TAX DEFAULT INFORMATION
CERTIFICATION
Authorized Representative's Name, Title - Print name and the title of the representative authorized to sign for the company.
Authorized Representative's Signature, Date - Authorized representative signature and date form was signed.
Telephone Number, Fax Number, Email Address - Authorized representative's telephone number, fax number, and, if applicable,
Email address.
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NOTICE OF TAX PAYMENT DEFAULT (Virginia Department of Motor Vehicles)

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Completed 2 November 2020

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