CITY OF LAKEWOOD
PHN 303-987-7630
SALES AND USE TAX RETURN
TDD 303-987-7057
REVENUE DIVISION
BELMAR
FAX 303-987-7662
PO BOX 261450
LAKEWOOD, CO 80226-9450
PRINT FORM
CLEAR FORM
REVISED 10/10/06
***PLEASE DO NOT STAPLE OR TAPE ANYTHING TO THIS FORM***
TAXPAYER'S NAME AND ADDRESS
--Select One--
PERIOD:
--Select One--
DUE DATE:
LICENSE #:
(FROM LINE 3L)
GROSS SALES AND SERVICE
1
5A
AMOUNT OF CITY SALES TAX :$__________________________ X3%
(Non-Grocery Items shipped out of Belmar)
HOTEL/MOTEL ACCOMMODATIONS TAX $_________________ X 3%
2A
ADD: BAD DEBTS COLLECTED
5B
(FROM LINE 3J)
TOTAL OF LINES 1 AND 2A
GROCERIES SUBJECT TO TAX: $________________________ X 2%
2B
5C
(Groceries shipped out of Belmar)
(FROM LINE 4)
NON-TAXABLE SERVICE SALES
3A
5D
AMOUNT OF CITY SALES TAX :$__________________________ X1%
SALES TO OTHER LICENSED
ADD: EXCESS TAX COLLECTED:
3B
6
DEALERS FOR RESALE
TOTAL SALES TAX COLLECTED: ADD LINES 5A, 5B, 5C, 5D & LINE 6
7
SALES SHIPPED OUT OF LAKEWOOD
3C
8
3D
BAD DEBTS CHARGED OFF
9
TRADE-INS FOR TAXABLE
CITY USE TAX (FROM SCHEDULE B)
3E
RESALE
10
SALES OF GASOLINE AND
PURCHASES SUBJECT TO TAX: $________________________ x 3%
3F
CIGARETTES
SALES TO GOV'T, RELIGIOUS, AND
TOTAL TAX DUE ADD LINES 7 & 10
3G
11
CHARITABLE ORGANIZATIONS
IF FILED
RETURNED GOODS
10% PENALTY
3H
MULTIPLY PENALTY
AFTER THE
& INTEREST BY
12
DUE DATE
LINE 11
INTEREST 1.4% PER MONTH
3I
PRESCRIPTION DRUGS
ADD:
GROCERY FOOD SALES SHIPPED
TOTAL TAX, PENALTY, AND INTEREST DUE
OUTSIDE OF BELMAR BUT WITHIN
3J
13
ADD LINES 11 AND 12
LAKEWOOD
PUBLIC IMPROVEMENT FEE
COLLECTED ON NON TAXABLE
A. ADD: PRIOR PERIOD ADJUSTMENT
3K
PURCHASES
ITEMS SHIPPED OUT OF BELMAR
14
3L
BUT WITHIN LAKEWOOD
B. DEDUCT: PRIOR PERIOD ADJUSTMENT
OTHER DEDUCTIONS
3M
TOTAL DEDUCTIONS OF LINES 3A THROUGH 3M
3
ADD LINES 13, 14A & 14B
TOTAL DUE AND
15
MAKE CHECK OR MONEY ORDER PAYABLE
PAYABLE
TOTAL CITY NET TAXABLE SALES & SERVICE -
TO CITY OF LAKEWOOD
4
SUBTRACT LINE 3 (TOTAL DEDUCTIONS) FROM LINE 2B
SCHEDULE B - CITY USE TAX
The Lakewood Municipal Code imposes a tax upon the privilege of using, storing or otherwise consuming in the City tangible property or taxable services purchased, rented or leased.
DATE OF PURCHASE
NAME OF VENDOR & ADDRESS
TYPE OF COMMODITY PURCHASED
PURCHASE PRICE
TOTAL PURCHASE PRICE OF PROPERTY/SERVICE SUBJECT TO CITY USE TAX ENTER TOTAL HERE AND ABOVE ON LINE 10
LINE 10
NOTES
1. If ownership has changed, give date of change and
SHOW CHANGE OF OWNERSHIP, NAME AND/OR ADDRESS, ETC
I HEREBY CERTIFY UNDER PENALTY OF PERJURY, THAT THE
new owners name.
NEW BUSINESS DATE
STATEMENTS MADE HEREIN ARE TO THE BEST OF MY
KNOWLEDGE, TRUE AND CORRECT.
MO
DATE
YEAR
BUSINESS ADDRESS
MAILING ADDRESS
2. If business has been permanently terminated,
__________________________________
SIGN:
give termination date.
__________________________________
TERMINATION DATE
PHONE:
MO
DATE
YEAR
3. If business location has changed give new address.
__________________________________
TITLE:
DATE: