Form Fr-27c - 2005 - Gross Receipts Tax Monthly Returns For Cable Television, Satellite Relay Or Distribution Of Video Or Radio Transmissions - Office Of Tax And Revenue - Government Of The District Of Columbia Page 4
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6DESCRIPTION
AMOUNT
GROSS RECEIPTS MONTHLY RETURN FOR
CABLE TELEVISION, SATELLITE RELAY OR
1. Total Amount Subject to Tax
$
DISTRIBUTION OF VIDEO OR RADIO
REVERSE SIDE
2. Less Allowable Deductions
Government of the District of Columbia
MUST BE
Office of the Chief Financial Officer
COMPLETED
3. Taxable Gross Receipts
Office of Tax and Revenue
4. Tax Rate
10%
Federal Employer Identification Number (FEIN)
OFFICIAL USE
5. Total Tax Due
$
6. Penalty (Late Filing and Payment)
MONTH ENDING
DUE DATE
7. Interest
8. Total Amount Due
BUSINESS NAME
9. Total Amount Paid
$
Under penalties of law, I declare that I have examined this return and to the best of my knowledge,
it is correct. Declaration of paid preparer is based on all the information available to the preparer.
ADDRESS
SIGNATURE
DATE
CITY
STATE
ZIP CODE
TITLE
PHONE #
Mailing Instructions: Make check or money order payable to the DC Treasurer. Identify the tax payment
and mail to the Office of Tax and Revenue, Excise Taxes, PO Box 556, Washington DC 20044-0556.
Signature of preparer if other than full-time employee of taxpayer
(REV. 04/05)
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