Form: Os - 3105 - Business Gross Revenue Tax Quarterly Return

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DIVISION OF REVENUE AND TAXATION
COMMONWEALTH GOVERNMENT OF THE NORTHERN MARIANA ISLANDS
BUSINESS GROSS REVENUE TAX QUARTERLY RETURN
20
DLN
(Please Type or print in ink)
(See reverse side of this form for instructions)
A. 1. Taxpayer’s Name
C. 1. Taxpayer’s Identification Number (TIN)
F. MARK HERE IF THIS IS
A FINAL RETURN AND
INDICATE THE DATE WHEN
A. 2. Doing Business As
C. 2. TIN previously reported, if different from above
BUSINESS WAS CLOSED OR
DISSOLVED
B. Mailing Address
D. Quarter Ended
E. Telephone Number (s)
:
CHECK IF
AMENDED
CONSOLIDATED
ORIGINAL
DATE
I. ACTIVITIES
G. BUSINESS FORM
H. LOCATION OF BUSINESS
LAND LEASE
BARBER/BEAUTY SHOP
SOLE PROPRIETORSHIP
RETAILING
PARTNERSHIP
S A I P A N
TINIAN
NIGHT CLUB
CONSTRUCTION
HOUSE RENTAL (UNITS
)
C O R P O R AT I O N
A SS O C I AT I O N
R O TA
NORTHERN IS.
SERVICES
TAILORING SHOP
NON-PROFIT ORGANIZATION
OCEAN SHIPPING
OTHERS
Indicate Village
(Specify each separately)
FOR OFFICIAL
J. COMPUTATION OF TAX AND OTHER CHARGES
USE ONLY
1.
TOTAL REVENUE FOR THE PERIOD JANUARY 1 - MARCH 31.
2.
TOTAL REVENUE FOR THE PERIOD APRIL 1 - JUNE 30.
3.
TOTAL REVENUE FOR THE PERIOD JULY 1 - SEPTEMBER 30.
4.
TOTAL REVENUE FOR THE PERIOD OF OCTOBER 1 - DECEMBER 31.
5.
TOTAL LINES 1,2,3, AND 4.
LESS REVENUE NOT SUBJECT TO TAX ( attached detailed statement of explanation)
6.
GROSS REVENUE SUBJECT TO TAX (line 5 minus line 6)
7.
8.
TAX ON AMOUNT SHOWN ON LINE 7.
9.
TAX ALLOCATED PREVIOUS QUARTER(S). Current year only.
10.
TAX ALLOCATED THIS QUARTER. (line 8 minus line 9).
11.
ENTER AMOUNT PAID THIS QUARTER FROM FORM 500-BGRT-BWH.
12.
TAX (OVERPAID) FROM PREVIOUS QUARTERS, IF ANY.
13.
TAX DUE (OVERPAYMENT) THIS QUARTER. ( line 10 minus lines 11 and 12, it any)
14a. ENTER AMOUNT OF EDUCATIONAL CASH CONTRIBUTIONS MADE THIS YEAR
14b. ENTER EDUCATION TAX CREDIT TAKEN PRIOR QUARTER(S)
14c. EDUCATION TAX CREDIT AVAILABLE THIS QUARTER
14d. EDUCATION TAX CREDIT (see instructions/attach Schedule ETC)
15a. OVERPAYMENT CREDIT FROM FORM 1120CM OR 1040 CM, IF ANY.
(See instructions)
15b. ENTER YEAR OF RETURN FOR WHICH CREDIT WILL BE APPLIED FROM
15c. ENTER TYPE OF RETURN FOR WHICH CREDIT WILL BE APPLIED FROM
16.
TAX AFTER CREDIT. ( line 13 minus lines 14 and 15a)
PENALTY CHARGE (if return is filed and paid after the deadline, complete this
17.
17a (10%)
line.)
17b ( 1%)
18.
INTEREST CHARGES. (if payment is made after the deadline, complete this line.)
PAY THIS AMOUNT
19.
TOTAL DUE (Add lines 16, 17a, 17b, and 18)
K. DECLARATION: Under the penalties of perjury, I declare that this return is, to the best of my knowledge and belief, true and correct.
Date
Name (Typed) and Signature
Title
PAID
Date:
Preparer’s SSN:
TIN:
Preparer’s Signature:
PREPARER’S
USE ONLY
Firm’s Name
Mailing Address
FOR OFFICIAL USE ONLY
Account No:
Account No:
Account No:
Account No:
Amount:
Amount:
Amount:
Amount:
Received By:
POST MARK:
RECEIPT NO:
DATE PAID:
INPUT BY:
INPUT DATE:
VERIFIED BY:
Form: OS - 3105 (Rev. 1/2004)
NOTE: This revision is effective 4th Quarter 2004

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