Food And Beverage Tax Form - 2014

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FOOD AND BEVERAGE TAX
COUNTY OF HENRICO, VIRGINIA
DEPARTMENT OF FINANCE
1. Gross Sales
$__________________
(804) 501-7354 or (804) 501-7329
2. Non- Taxable Sales and Other Deductions
$__________________
3. Taxable Sales
$__________________
(Line 1 less Line 2)
Collections for the Period Ending:
4. Food and Beverage Tax
$__________________
(Line 3 X 4%)
5. Seller’s Commission
$__________________
(Line 4 X 3%)
_____________________________________
Account Number
(only if the return is filed and the tax paid in full by the due date)
Name & Address
6. Subtotal
$__________________
(Line 4 less Line 5)
7. Penalty for Late Filing
$__________________
(Line 6 X 10%)
8. Penalty for Late Payment
$__________________
[(Lines 6 + 7) X 10%]
9. Sum of Lines 6, 7, and 8
$__________________
10. Interest if Late
$__________________
(Line 9 X a daily rate of .0274%)
I declare that the forgoing statements are true, full and correct
11. Total Due
$__________________
(Line 9 + Line 10)
to the best of my knowledge.
12. Amount Paid
$__________________
__________________________________________
Signature
Date
th
Due by the 20
day of the month following the end of the reporting period.
______________________
________________
Mail To: County of Henrico, PO Box 90777, Henrico, VA 23228-0777
Title
Phone
Rev 6/14 SL
FOOD AND BEVERAGE TAX
COUNTY OF HENRICO, VIRGINIA
DEPARTMENT OF FINANCE
1. Gross Sales
$__________________
(804) 501-7354 or (804) 501-7329
2. Non- Taxable Sales and Other Deductions
$__________________
3. Taxable Sales
$__________________
(Line 1 less Line 2)
Collections for the Period Ending:
4. Food and Beverage Tax
$__________________
(Line 3 X 4%)
5. Seller’s Commission
$__________________
(Line 4 X 3%)
_____________________________________
Account Number
(only if the return is filed and the tax paid in full by the due date)
Name & Address
6. Subtotal
$__________________
(Line 4 less Line 5)
7. Penalty for Late Filing
$__________________
(Line 6 X 10%)
8. Penalty for Late Payment
$__________________
[(Lines 6 + 7) X 10%]
9. Sum of Lines 6, 7, and 8
$__________________
10. Interest if Late
$__________________
(Line 9 X a daily rate of .0274%)
I declare that the forgoing statements are true, full and correct
11. Total Due
$__________________
(Line 9 + Line 10)
to the best of my knowledge.
12. Amount Paid
$__________________
__________________________________________
Signature
Date
Due by the 20
th
day of the month following the end of the reporting period.
______________________
________________
Mail To: County of Henrico, PO Box 90777, Henrico, VA 23228-0777
Title
Phone
Rev 6/14 SL
FOOD AND BEVERAGE TAX
COUNTY OF HENRICO, VIRGINIA
DEPARTMENT OF FINANCE
1. Gross Sales
$__________________
(804) 501-7354 or (804) 501-7329
2. Non- Taxable Sales and Other Deductions
$__________________
3. Taxable Sales
$__________________
(Line 1 less Line 2)
Collections for the Period Ending:
4. Food and Beverage Tax
$__________________
(Line 3 X 4%)
5. Seller’s Commission
$__________________
(Line 4 X 3%)
_____________________________________
Account Number
(only if the return is filed and the tax paid in full by the due date)
Name & Address
6. Subtotal
$__________________
(Line 4 less Line 5)
7. Penalty for Late Filing
$__________________
(Line 6 X 10%)
8. Penalty for Late Payment
$__________________
[(Lines 6 + 7) X 10%]
9. Sum of Lines 6, 7, and 8
$__________________
10. Interest if Late
$__________________
(Line 9 X a daily rate of .0274%)
I declare that the forgoing statements are true, full and correct
11. Total Due
$__________________
(Line 9 + Line 10)
to the best of my knowledge.
12. Amount Paid
$__________________
__________________________________________
Signature
Date
Due by the 20
th
day of the month following the end of the reporting period.
______________________
________________
Mail To: County of Henrico, PO Box 90777, Henrico, VA 23228-0777
Title
Phone
Rev 6/14 SL

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