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RV-R0003701

INTERNET (8-16)

TENNESSEE DEPARTMENT OF REVENUE

For assistance, contact the Taxpayer Services Division at

Gross Receipts Tax Return - Bottlers & Manufacturers of Soft Drinks

(800) 342-1003, (615) 253-0600 or

Reporting Period

Account No.

Taxable Period

GRO

Month

Day

Year

Beginning:

200

Ending:

Please indicate the annual or monthly reporting period

Due Date

SSN OR FEIN

}

If this is an AMENDED RETURN,

please check the box at right

If this is a FINAL RETURN for a

}

closed

business, please check

the box at right

If this is a CHANGE OF MAILING

}

ADDRESS, please check the box

at right

TENNESSEE DEPARTMENT OF REVENUE

Remit amount shown

Andrew Jackson State Office Building

in Line 16, payable to:

500 Deaderick Street, Nashville, TN 37242

ROUND TO NEAREST DOLLAR

.00

1. Gross receipts from bottled soft drinks manufactured or produced and sold in Tennessee..............................(1)

2. Purchase price of bottled soft drinks obtained from out-of-state suppliers on which supplier paid the tax.......(2)

.00

3. Purchase price of bottled soft drinks obtained from out-of-state suppliers on which you are paying the tax....(3)

.00

4. Taxable amount (Add Lines 1 and 3)...................................................................................................................(4)

.00

5. Soft Drink Tax (

% of Line 4)..............................................................................................................(5)

6. Credit for franchise tax paid...............................................................

.........................(6)

.00

7. Credit for excise tax paid...................................................................

.........................(7)

8. Net Soft Drink Tax (Line 5 less Lines 6 and 7).....................................................................................................(8)

.00

9. Litter control amount (

% of Line 4).........................................................................................................(9)

.00

10. Total Tax (Add Lines 8 and 9)............................................................................................................................(10)

11. Credit memo balance..........................................................................................................................................(11)

.00

If filed LATE, compute penalty at 5% of the tax (Line 10 less Line 11) for each 1 to 30-DAY PERIOD for which TAX IS DELINQUENT. (Total

12. PENALTY{

.00

(12)

penalty not to exceed 25%). Minimum penalty is $15 regardless of the amount of tax due or whether there is any tax due.

13. INTEREST - If filed late, compute interest at

% per annum on the tax (Line 10 minus Line 11) from the

.00

due date to the date of payment.......................................................................................................................(13)

14. Total amount due - Add lines 10, 12 and 13 less Line 11 if applicable...............................................................(14)

.00

15. Installment (1/4 of Line 14) - (Only timely annual filers have the option to use this line).....................(15)

.00

16. Total amount due (Line 14 or Line 15)................................................................................................................(16)

.00

I declare this is a true, complete, and accurate return to the best of my knowledge.

FOR OFFICE USE ONLY

SIGN

HERE

President or other Principal Officer, Partner or Proprietor

Date

SIGN

HERE

Tax Return Preparer and Title

Date

20012000000000000000000000000000000000000000000000000000000000000000