Form A-11 - Business & Occupation Activities Return - 2011
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5January - December 2011
Mail to:
State of Washington
A
11
Department of Revenue
Business & Occupation Activities Return
PO Box 34051
Seattle, WA 98124-1051
Tax Registration Number
Use Black Ink &
4
Name
Return Original Form.
Business Name
Street Address
City, State, Zip
Has Your Address Changed?
Filing an Amended Return?
If so, check appropriate box(es) below and note changes on address above.
Business Closed?
Check this box and enter date closed.
Effective date of change
Check this box and attach amended return
information and a letter of explanation.
Business Location Change
Mailing Address Change
Other Correspondence?
I. State Business and Occupation (B&O) Tax
Travel Agent Comm/Tour Operator; Intl Charter Freight Brokers; Stevedoring; Licensed Boarding Homes [28]
1.
Gross Amount
Deductions*
Taxable Amount
Rate
Tax Due
.
,
,
,
,
.
,
.
,
.
,
X
-
=
.00275
Insurance Producers; Title Insurance Agents; Surplus Line Broker Commissions [14]
2.
Gross Amount
Taxable Amount
Tax Due
Deductions*
Rate
.
,
,
.
,
.
,
,
.
,
,
X
-
=
.00484
3.
Royalties; Child Care [80]
Gross Amount
Taxable Amount
Tax Due
Deductions*
Rate
,
.
,
.
,
.
,
,
.
,
,
X
-
=
.00484
4.
Wholesaling [03]
Gross Amount
Deductions*
Taxable Amount
Rate
Tax Due
.
,
.
,
,
,
,
.
,
,
.
X
-
=
.00484
5.
For Profit Hospitals; Scientific R&D [135]
Gross Amount
Taxable Amount
Tax Due
Deductions*
Rate
.
,
,
.
,
.
,
,
.
,
,
X
-
=
.015
Service & Other Activities [04]
6.
Gross Amount
Taxable Amount
Tax Due
Deductions*
Rate
,
.
,
.
,
.
,
,
.
,
,
X
-
=
.018
*
Deductions taken but not itemized on pages 3 & 4 will be disallowed.
State and Local Use Tax/Deferred Sales Tax (See page 2.)
4
DUE DATE: January 31, 2012
IV. Totals
* 5% Penalty Assessed After January 31, 2012
15% Penalty Assessed After February 29, 2012
,
,
.
18. Total Tax Due from Section I
25% Penalty Assessed After April 02, 2012
(Tax due from lines 1-6)
If the due date falls on a weekend or legal holiday,
the due date is extended to the next business day.
,
,
.
19. Total Tax Due from Section II
(Tax due from line 12)
No Business Activity?
File by telephone: Call 1-800-647-7706.
20. Total All Addendums
,
(Example:
,
.
At the greeting, enter code 111 to start the process. Enter your 9-digit
Local Sales/Use Tax)
tax registration number and follow the instructions given. If you file by
telephone, do not mail us your return; or
,
,
.
21. Subtotal
(add lines 18-20)
If you have no business activity and did not file by telephone, check this
box, sign and mail us your return.
,
,
.
22. Total Credit from Section III
4
Make check or money order payable to the Washington State Department
(from page 2, line 17)
of Revenue.
,
,
4
.
Please write your tax registration number on your check.
23. Subtotal
(subtract line 22
from line 21)
4
Signature
,
,
.
24. * Add Penalty,
if Applicable
4
Print Name
(Minimum $5.00)
%
(
)
/
/
4
Phone Number
Date
,
,
.
Total Amount Due
25.
Internet/Fax
(10-25-11)
Page
1
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