Form 163 - Sales Tax Protest Payment Affidavit Page 3
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Page 3
This schedule is to be used only if the space provided on page 1 of the Protest Affidavit is insufficient to report all protest payments.
To complete Schedule A, refer to instructions on page 3.
Adjustments
Tax
Business Location
Tax Type
Gross Receipts
Taxable Sales
Amount of Tax
Rate (%)
Indicate + or – )
-
State
3%
City:
-
Conservation
1/8%
-
Education
1%
Location Code:
-
Parks and Soil
1/10%
City: __ __ __ __ __
-
-
County: __ __ __
-
Site: __ __ __ __
-
-
Reset This Section Only
-
-
-
-
-
-
-
Adjustments
Tax
Business Location
Tax Type
Taxable Sales
Gross Receipts
Rate (%)
Indicate + or – )
-
State
3%
City:
-
Conservation
1/8%
-
Education
1%
Location Code:
-
Parks and Soil
1/10%
-
City: __ __ __ __ __
-
County: __ __ __
-
Site: __ __ __ __
-
-
Reset This Section Only
-
-
-
-
-
-
-
Adjustments
Tax
Business Location
Tax Type
Gross Receipts
Taxable Sales
Amount of Tax
Rate (%)
Indicate + or – )
-
City:
State
3%
-
Conservation
1/8%
-
Education
1%
Location Code:
-
Parks and Soil
1/10%
City: __ __ __ __ __
-
County: __ __ __
-
Site: __ __ __ __
-
-
Reset This Section Only
-
-
-
-
-
-
-
Enter total amount of tax
Enter total amount on page 1
Form 163 (Revised 12-2014)
*14008030001*
14008030001
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Parent category: Financial