Form Boe-403-Clw - Use Tax Return Worksheet For Purchases

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USE TAX RETURN WORKSHEET

BOE-403-CLW (FRONT) REV. 2 (2-09)

FOR PURCHASES MADE FROM

THROUGH

Reference No:

___________________

____________________

DUE

DBA:

________________

ITEM PURCHASED

A/S

PURCHASE

LOCATION USED

PURCHASE PRICE

TAX

VENDOR

DATE

RATE

Total from attached spreadsheet(s)

TOTAL (sum of lines 1–23)

Credit for sales tax paid to any other state(s) for purchases listed above. Attach copies of

invoices showing the amount of sales tax paid in other states.

Balance of Tax Due (line 24 less line 25)

PENALTY of 10% (0.10) is due on tax paid after the due date. See instruction for line 27.

INTEREST: One month’s interest is due on tax for each month or fraction of a month that

payment is made after the due date. See instruction for line 28.

Total Due – (sum of lines 26–28) Mail with payment to PO Box 942879, Sacramento, CA 94279-0098

I certify to the best of my knowledge that I am a corporate officer, partner, owner, or hold a power of attorney to execute this document and that to the best of my knowledge the amounts

reported are a true and complete reporting of purchases of supplies, fixtures, and equipment for use in this state without the payment of California use tax.

Sign, date, and provide contact information on each return worksheet and submit them with payment in full by the response date referenced in the letter. Keep a copy for your records.

NAME (print)

DATE

PHONE (include area code)

SIGNATURE

TITLE

EMAIL ADDRESS

CLEAR