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Part A

Sales of Services substantially performed in other States

The proceeds of the sale of goods, wares, or merchandise returned by the customer when the sales price is refunded

either in cash or in credit. Line E, Schedule A, State Sales Tax Return

Bona Fide Sales in Interstate Commerce where the purchaser takes possession outside of Tennessee for use or

consumption outside of Tennessee and item is actually delivered by the seller of common carrier.

Cash discounts allowed and taken on sales. Line J, Schedule A, State Sales Tax Return

Repossessions--Enter that portion of the unpaid principal balances in excess of $500.00 due on tangible personal

properties repossessed from customers. (Line H, Schedule A, State Sales Tax Return.)

The amounts allowed at trade-in value for any article sold

Amounts subcontracted to other persons for additions or improvements to real property. Attach list of subcontractors and

addresses, items subcontracted and amounts.

TOTAL – Part A -- add lines 1-7

Part B

1. FUEL TAX

a. Gasoline Tax Paid:

# of Gallons

.......................................

Federal

.................................................

# of Gallons

State

b. Diesel Fuel Use Tax Paid:

.............................

# of Gallons

.......................................

Federal

# of Gallons

State

c. State Special Tax:

.................................................

# of Gallons

...........................................................

d. Liquefied Gas:

.................................................

# of Gallons

.......................................

Federal

# of Gallons

State

2. TOBACCO TAX

TOTAL FUEL B(1)

a. Cigarettes:

...........................................................

# of Packs

.......................................

Federal

# of Packs

State

................................................................................................................................

b. Other Tobacco Products:

Federal

State

3. BEER

TOTAL TOBACCO B(2)

.................................................

a. Beer:

Gallons

Barrels

Federal

...................

Gallons

Barrels

State

b. 17% of Wholesaler's Cost per beer sold:

......................................................................................................................

TOTAL BEER B(3)

OTHER DEDUCTIONS

Other:

TOTAL B(4)

TOTAL – Part B -- add Totals for B1-B4..............................................................................................

TOTAL PART B

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Part C--Total Deductions for Schedule A

Totals Parts A and B

Place Part C total on Line 2 on front side of report............................................................................

NOTE: All deductions must have adequate records maintained to substantiate deductions claimed, otherwise they will be disallowed.

Returns Filed For More Than One Location

If return is filed for more than one location, list address and amount of Gross Sales of each.

Street, Address, City, State, Zip

Gross Sales

Deductions

CREDIT CARD OPTION

If you choose the Credit Card Option, the total amount to be

VISA

MasterCard

Discover

charge to your credit card is listed below.

Total Tax Due

#DIV/0!

16-Digit Credit Card Number

Expiration Date

Processing Fee*

Payment Amount

Fee*

Less than $150

2.95%

Name as it Appears On Card

Card Statement Zip Code

Greater than $150

2.65%

NOTE: There is a minimum fee of $1.49

Amount Charged to Card

#DIV/0!

Your card will be charged only if credit card info is completed.

Signature

Date

Daytime Phone

Application For Business Tax License And Report Form - Hamilton County, Tennessee (Expired 2002) Page 2

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