Meals Tax Form - Virginia

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OFFICE OF THE COMMISSIONER OF THE REVENUE
County of Stafford, Virginia
Phone (540) 658 - 4132
Remittance of Tax on
MEALS TAX
Account: _______________
Name and Address: _______________________________________
Telephone: (
) _________ -- ____________
_______________________________________
_______________________________________
Remittance for Month of ______________ , _______
1. Gross Receipts
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ........................................
2. Less Allowable Deductions (Attach List)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ........................................
3. Taxable Balance (Item 1 - Item 2)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ........................................
4.00
4. Tax on Item 3 at
%
. . . . . . . . . . . . . . . . .
$ ........................................
10.00
5. Penalty for Late Payment on Item 4 at
%
. . . . . . . . . . . . . . . . .
$ ........................................
6. Balance (Item 4 + Item 5)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ........................................
$ ........................................
10.00
7. Interest (per annum) for Late Payment on Item 6 at
%
. . . . . . . . . . . . . . . . .
$ ........................................
8. Total Due [Tax, Penalty and Interest] (Item 6 + Item 7)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9. Amount Paid (Check # .................................)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ........................................
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 :
.....................................
Signed by :
........................................................................................
Phone Number :
.....................................
Title :
........................................................................................
INSTRUCTIONS :
MAKE CHECK PAYABLE TO: STAFFORD COUNTY TREASURER
Mail completed form, with check, on or before 20th of month following period end.
To:
SCOTT A. MAYAUSKY
Commissioner of the Revenue
P.O. Box 98
Stafford, Virginia 22555-0098
MEALS TAX
For Office Use Only -
54
RCS Menu Code:
Account: _______________
Name and Address: _______________________________________
Telephone: (
) _________ -- ____________
_______________________________________
_______________________________________
Remittance for Month of ______________ , _______
Check #:
...............................
Amount $: .....................................................................
.........................................
Received by:
.................................................................................................................
Date received in Office
Office of Stafford County Commissioner of the Revenue
Form Last Revised: 05/21/2009

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