Prepared Food & Beverage Tax Return Form - Office Of The Tax Administrator, North Carolina
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1Office of the Tax Administrator
•
•
•
117 Dick Street
P.O. Box 449
Fayetteville, North Carolina
28302-0449
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(910) 678-7590
Fax (910) 678-7582
PREPARED FOOD & BEVERAGE TAX RETURN
(TO BE FILED & PAID WITHIN 25 DAYS FROM THE CLOSE OF EACH MONTH)
PLEASE READ CAREFULLY INSTRUCTIONS PRINTED ON BACK FOR COMPLETING THIS FORM
For The Month Of
, 20
Account Number
Trade Name
Social Security or Federal ID Number
Mailing Address
Business Phone Number
City
State
Zip Code
Street Address of Property
Owner of Business – Name
Address
Phone No.
COLUMN A
COLUMN B
SALES
TAX DUE
1. Gross Retail Receipts (Excluding Sales Tax)
$
2. Less: Non-prepared Food/Beverage Receipts
$
3. Net Retail Prepared Food/Beverage Receipts
$
4. Prepared Food/Beverage Tax Due:
(Multiply Amount on Line 3 by Tax Rate of 1%)
$
5. Excess Tax Collected
$
6. Penalty Due: Failure to File Timely
*See Back of Form
$
(5% of tax per month – Min $5.00)*
7. Penalty Due: Failure to Pay Timely
$
*See Back of Form
(10% of tax – Min $5.00)*
8. TOTAL TAX/PENALTY REMITTED
(Make Check Payable to County Tax Collector)
$
* IF YOU HAVE HAD ANY CHANGES SINCE YOUR LAST RETURN, PLEASE COMPLETE THE FOLLOWING:
Final Return
Change of Ownership
Please cancel my account as of
/
/
Mailing Address
Location Address
Indicate Reason:
Phone Number
Trade Name
If business was sold, Date Sold
/
/
To whom was business sold?
CERTIFICATION.
This is to certify that this report, including all statements and schedules attached hereto, has been examined
by me, and is, to the best of my knowledge and belief, a true and complete report made in good faith covering the month named
above and that same is in accordance with the records of the reporting taxpayer..
Date
Name-Please Print
Signature
THIS SPACE FOR TAX OFFICE USE ONLY
DATE RECEIVED
Return PM
_________
AMOUNT REMITTED
Payment PM
RECEIVED BY
_________
RETURN TO CUMBERLAND COUNTY WITH REMITTANCE
1/07
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