Mail Remittance And Return Form Above Address Made Payable

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CITY OF DICKSON
City Tax Collector
600 East Walnut Street
Dickson, TN 37055
(615) 441-9503
Accommodation Tax
Mail Remittance & Return Form to
Private Chapter No. 59
above address made payable to
Private Acts of 2001
City of Dickson, Tax Collector
_________________________________
____________________________________
Name of Owner(s)
Hotel/Motel Name
_________________________________
____________________________________
State Sales Tax Account No.
Location
_______________ ________________
____________________________________
Telephone No.
No. of Rooms
Mailing Address
____________________________________
City
State
Zip
MONTH OF ________________ 20______
Gross Rental receipts from Occupancy …………………….……………….. $___________________________
1.
2. Less: Allowable Deductible and/or Excludable Receipts………………….. $___________________________
3. Taxable Receipts (line 1 less line 2)………………………………………... $___________________________
4. Tax due (5% of line 3)………………………………………...………….
$___________________________
OPERATOR’S COMPENSATION:
5.
Deduct 2% of line 4 (allowable only if return is filled
th
of each month)………………………………………$____________________________
and tax is paid by 20
Interest @ 12% per annum………………………………………………….$____________________________.
6.
Penalty @ 1% per month……………………………………………………$____________________________
7.
Total Interest and Penalty (add lines 6 and 7)……………………………… $____________________________
8.
9. TOTAL TAX DUE CITY OF DICKSON
(line 4 less line 5 if NOT DELINQUENT; if
delinquent, line 4 plus line 8)……………………………………………….. $_____________________________
RETURN AND REMITTANCE MUST BE IN THE ABOVE OFFICE BY THE CLOSE OF BUSINESS ON THE
TH
20
DAY OF THE MONTH FOLLOWING THE MONTH ON WHICH THIS REPORT IS SUBMITTED.
Under the penalties for perjury prescribed by law, I swear (or affirm) that this return (including any related
schedules, statements and/or other documents) is, to the best of my belief and knowledge, a true, correct and
complete return.
______________________________ Title_______________________ Date___________
Signed

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