Gross Receipts Tax Monthly Report Form

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READ INSTRUCTIONS ON REVERSE SIDE
CITY OF WEST MEMPHIS
GROSS RECEIPTS TAX MONTHLY REPORT
Required by City Ordinance #917 (as amended)
FOR THE MONTH
OR MONTHS OF
20
NOTICE
BUSINESS NAME
MAKE CHECK PAYABLE TO
OWNER’S NAME
CITY ADVERTISING AND
PROMOTION FUND
ADDRESS
MAIL TO
CITY CLERK’S OFFICE
TYPE OF BUSINESS
P.O. BOX 1728
WEST MEMPHIS, AR 72303
STATE TAX ID#
1.
Gross Receipts
$
(Total of cash and credit sales) See Provisions of Ordinance #917
in Instructions #1 on reverse side
2.
DEDUCTIONS allowed by State Acts
$
See reverse side, Instruction #5
Taxable Receipts
$
NOTICE
Tax Due
$
Total Gross and taxable
(2% of Taxable Receipts)
receipts shown on this report
must agree with total amount
reported to State Revenue
Commissioner_________ $ ___________
Penalty
$
(Gross Receipts)
(See reverse side, Instructions #3)
$ ___________
Total Tax and Penalty
$
(Taxable Receipts)
Memorandum Credit Attached
$
This Remittance
$
I hereby state, and affirm that the statements contained herein are full; true and correct as required by City
Ordinance #917 and provisions of Arkansas Gross Receipts Tax Law (Act 386 of 1941 and Act 185 of 1965), which
established rules and regulations for assessment, administration, collection and enforcement of the tax.
___________________________________________________ Date this report prepared ________________ 20 _____
Must be signed by owner or authorized agents

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