Form Et-179b - Local Tax Rebate Supplemental Sheet

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Business Name: ________________________________
Permit: ________________________________
Local Tax Rebate Supplemental Sheet Form ET-179B
22) Invoice Amount
18) City/County Where
20) Invoice Total Amount
16) Invoice Number
17) Invoice Date
19) City/County Code
21) Standard Cap Amount
Eligible for Rebate (Block
23) Local Tax Rate
24) Rebate Amount
Purchased or Delivered/Shipped
(Do Not Include Tax Paid)
20 minus Block 21)
- $2,500.00 =
X
% =
- $2,500.00 =
X
% =
- $2,500.00 =
X
% =
- $2,500.00 =
X
% =
- $2,500.00 =
X
% =
- $2,500.00 =
X
% =
- $2,500.00 =
X
% =
- $2,500.00 =
X
% =
- $2,500.00 =
X
% =
- $2,500.00 =
X
% =
- $2,500.00 =
X
% =
- $2,500.00 =
X
% =
- $2,500.00 =
X
% =
- $2,500.00 =
X
% =
- $2,500.00 =
X
% =
- $2,500.00 =
X
% =
- $2,500.00 =
X
% =
- $2,500.00 =
X
% =
- $2,500.00 =
X
% =
- $2,500.00 =
X
% =
Total Rebate Claim Amount (From the Invoices Listed
Above)(Enter this amount in Block 26 on Form ET-179A)

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