Form Rev 41 0065-4 - Natural Gas Use Tax Return Apr - May - Jun 2004
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4State of Washington
APR – MAY – JUN 2004
Q2
Department of Revenue
PO Box 47464
NATURAL GAS USE TAX RETURN
04
Olympia WA 98504-7464
Name
Reporting Acct. No
Tax
Firm Name
Show Changes in Address / Phone /
Street Address
Ownership and Date of Change
City, State, Zip
See Instructions on Page 4
Line
City
Volume
Transportation
Tax
Dept.
Purchase Price
Total Value
Tax Due
No.
Code
(In Therms)
Charges
Rate
Use Only
1
State
.03852
2
3
4
5
6
7
8
TOTAL
CREDITS
(Credits for Tax Paid in Another State)
Line
City
Consumer Paid
Seller Paid State
Seller Paid Municipal
TOTAL
No.
Code
Use Tax *
Gross Receipts
Gross Receipts Tax *
* This credit is to be split proportionally
among the locations. For example, if the
9
State
state’s portion of this tax constitutes 38.7
10
percent of the total tax, then 38.7 percent of
the credit is to be deducted from the state’s
11
portion of this tax.
TOTAL CREDITS
PRIOR PERIOD ADJUSTMENTS
Line
Type of
Amount
Explanation
No.
Adjustment
THIS RETURN IS DUE July 31, 2004
Dept.
Line
Totals
Tax Due
No.
Use Only
TAXPAYER MUST FILE A RETURN EVEN IF
Tax Due
+
13
NO TAX IS DUE
Less Credits
–
** Add Penalty If Paying After July 31, 2004
14
Minimum $5.00
Total Tax Due
=
15
5% After August 2, 2004
Penalty **
+
16
15% After August 31, 2004
25% After September 30, 2004
Interest
+
17
Signature
Less Adjustments
–
18
Telephone
Date
Total Payment Enclosed
=
19
For tax assistance, visit or call 1-800-647-7706. To inquire about the availability of this document in an alternate format
for the visually impaired, please call (360) 486-2342. Teletype (TTY) users may call 1-800-451-7985.
RETURN THIS COPY
REV 41 0065-1 (05/20/04)
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