Monthly Remittance Of Prepared Food And Beverages Tax - County Of Gloucester

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County of Gloucester
C
O
T
R
OMMISSIONER
F
HE
EVENUE
Courts and Office Building
6489 Main Street
Gloucester, Va. 23061
(804) 693-1318 or 693-3451 Fax (804) 693-3581
MONTHLY REMITTANCE OF PREPARED FOOD AND BEVERAGES TAX
NAME & ADDRESS:
TH
INSTRUCTIONS: MAIL WITH YOUR CHECK BEFORE THE 20
OF THE MONTH FOLLOWING THE MONTH BEING
REPORTED TO THE COMMISSIONER OF THE REVENUE AT THE ABOVE ADDRESS. MAKE YOUR CHECK PAYABLE
TO “TREASURER, GLOUCESTER COUNTY”.
BUSINESS LOCATION: __________________________________________
GROSS RECEIPTS FOR THE MONTH OF - ___________________
1
2
LESS ALLOWABLE DEDUCTIONS
3
BALANCE (TAXABLE) (LINE 1 MINUS LINE 2)
4
4% TAX ON LINE 3 (LINE 3 X .04)
5
PENALTY FOR LATE FILING AND PAYMENT (10% OF LINE 4)
6
INTEREST @ 10% PER ANNUM (LINES 4 & 5)
7
TOTAL TAX, PENALTY, INTEREST DUE AND PAID HEREWITH
DECLARATION OF SELLER:
I HEREBY SWEAR OR AFFIRM THAT THE AMOUNTS LISTED ABOVE ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE
.
AND BELIEF FOR THE PERIOD STATED ABOVE
DATE: _____________________________
SIGNATURE: ______________________________________________________
PHONE: ____________________________
TITLE: ___________________________________________________________
DATE RECEIVED ________________________________
BY___________________________________________________DEPUTY
COMMISSIONER OF REVENUE

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