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2. Estimated Gross Receipts
3. Actual Gross Receipts
5. Certification
   It is a misdemeanor for any person to willfully subscribe a return which is not believed to be true and correct as to every material matter (Code Va. Sec. 58.1-11).
7. Declaration
   I declare, under penalty of perjury, that the foregoing information is complete, true and correct to the best of my knowledge and belief.
9. Do you agree to the above declaration?*

   1. Yes

   1. No
11. First Name
12. Last Name
14. Title
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16. 1. Receive an email copy of this form.
17. Email address

    This field is not part of the form submission.

18. Submit

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