Form Cra - Combined Registration Application For State Of Delaware Business License And/or Withholding Agent - Division Of Revenue Page 11

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STATE OF DELAWARE
Mail This Copy With Remittance
INITIAL
Payable To
MONTHLY
Delaware Division of Revenue
P.O. Box 8995
EMPLOYER'S REPORT OF
Wilmington, DE 19899-8995
089 OR 090
DELAWARE TAX WITHHELD
DO NOT WRITE OR STAPLE IN THIS AREA
Employer Identification Number
FOR OFFICE USE ONLY
1
Social Security Number
2
Suffix
BUSINESS NAME AND ADDRESS
PAYMENT DUE DATE 15 days after end of month
PAYMENT FOR PERIOD
F
R
O
M
T
O
Month
Day
Year
Month
Day
Year
MAILING ADDRESS IF DIFFERENT
1. AMOUNT WITHHELD AND DUE FOR PERIOD
$
2. AMOUNT REMITTED
$
X
AUTHORIZED SIGNATURE (I DECLARE UNDER PENALTIES OF PERJURY THAT THIS IS A TRUE, CORRECT AND COMPLETE RETURN.)
DATE
TELEPHONE NUMBER
STATE OF DELAWARE
INITIAL
Mail This Copy With Remittance
QUARTERLY
Payable To
Delaware Division of Revenue
GROSS RECEIPTS
P.O. Box 2340
TAX RETURN
Wilmington, DE 19899-2340
028
DO NOT WRITE OR STAPLE IN THIS AREA
FOR OFFICE USE ONLY
Employer Identification Number
BUSINESS DESCRIPTION
1
S
B
Social Security Number
2
S
B
PAYMENT FOR QUARTER ENDING
PAYMENT DUE DATE
FILING PERIOD
BUSINESS NAME AND ADDRESS
Last day of first month
following the end of quarter
GROSS RECEIPTS
1. TOTAL GROSS RECEIPTS
$
2. LESS EXCLUSION
$
MAILING ADDRESS IF DIFFERENT
3. TAXABLE AMOUNT
$
TAX RATE
4. GROSS RECEIPTS TAX, LINE 3 X _______________ = $
5. APPROVED TAX CREDITS
$
6. BALANCE DUE. SUBTRACT LINE 5 FROM LINE 4
$
X
AUTHORIZED SIGNATURE (I DECLARE UNDER PENALTIES OF PERJURY THAT THIS IS A TRUE, CORRECT AND COMPLETE RETURN.)
DATE
TELEPHONE NUMBER

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