Form Dr-350111 - Intangible Tax Self_audit Worksheet Page 3
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8DR-350111
Intangible Tax
R. 06/07
Self-Audit Worksheet –
Page 3 0f 8
Name of taxpayer:
Social security number:
Name of spouse:
Social security number:
STOckS, MUTUAL FUNDS, MONEY MARkET FUNDS
Stock Code
schedule c
Do not write
AND LIMITED PARTNERShIP INTERESTS
in this space
class
Number
Just Value
Total
common
of
Per
Just Value
Verified
Name of company Issuing Stocks
or
Shares
Share
January 1, _____
by
(List alphabetically - do not abbreviate)
Preferred
(A)
(b)
(A x b)
10. TOTAL VALUE OF STOckS
Attach additional schedule if necessary. Photocopies of this schedule are acceptable.
cARRY ThIS AMOUNT TO SchEDULE A, LINE 2, PAgE 1 ...................................................................10.
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