Form F10 - City Lodging & Restaurant Tax - 2009

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Form
North Dakota Office of State Tax Commissioner
F10
City Lodging & Restaurant Tax
City Lodging Tax
(A)
Fill in this circle if this is an amended return.
Fill in this circle if you are no longer in business
and enter your last day of business.
(F)
Account
Due Date
Number
of Return
/
/
*Required (Ex: 999999 33)
Period
M M
D D
Y
Y
Y
Y
Ending
*Required (Ex: MM/DD/YYYY)
Fill in this circle if this business has changed
ownership. Provide name, address, and telephone
(C)
number of new owner:
Taxpayer Name
New Owner Name, Address, Phone Number
Address
City, State, ZIP Code
Fill in this circle if your address has changed.
Column A
Column B
CITY LODGING AND
CITY LODGING TAX
RESTAURANT TAX
(Lodging Only)
(Lodging, Food & Drinks)
RATE
%
RATE
%
.0 0
.0 0
1. Total Sales (do not include tax)
.0 0
.0 0
2. Nontaxable Sales
.0 0
.0 0
3. Net Taxable Sales (Subtract line 2 from line 1)
4. Tax Amount (Multiply line 3 by tax rate)
5. Penalty and Interest (See instructions)
6. Total Tax, Penalty and Interest (Add lines 4
and 5)
7. Total Due with Return (Add Column A and
Column B of line 6)
Make check or money order payable to North Dakota Tax Commissioner
I declare that this return has been examined by me and to the best of my knowledge and belief is a true, correct, and complete return.
Taxpayer
Signature
Date
Title
Contact Person
Contact Phone
Revised 07/01/2002
(Please print or type)
Number
Mail to:
Office of State Tax Commissioner
PO Box 5623
Bismarck, ND 58506-5623
Please Do Not
Write In This
Phone: 701-328-1246
Space
F-10
Taxpayer Copy
06/2009

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