Form Dr 15ez - Sales And Use Tax Return Page 2
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1
2DOLLARS
CENTS
,
,
1. Gross Sales
(Do not include tax)
Discretionary Sales Surtax Information
,
,
A. Taxable Sales and
,
2. Exempt Sales
Purchases Not Subject to
(Include these in Gross
Discretionary Sales
Sales, Line 1)
Surtax
,
,
3. Taxable Sales/Purchases
B. Total Discretionary
Sales Surtax Collected
,
4. Total Tax Collected
(Include Discretionary
Surtax from Line B)
,
5. Less Lawful Deductions
,
I hereby certify that this return has been examined by me and to the
6. Less DOR Credit Memo
best of my knowledge and belief is a true and complete return.
,
7. Total Tax Due
Signature of Taxpayer
Date
,
8. Less (-) Collection
Allowance; or if Late, Plus
(+) Penalty and Interest
,
Signature of Preparer
Date
9. Amount Due With Return
(Enter Line 9 on front)
Please do not fold or staple.
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