Form: Os - 3105 - Business Gross Revenue Tax Quarterly Return Page 2

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DIVISION OF REVENUE AND TAXATION
COMMONWEALTH GOVERNMENT OF THE NORTHERN MARIANA ISLANDS
BUSINESS GROSS REVENUE TAX QUARTERLY RETURN
SCHEDULE OF GROSS INCOME BY ACTIVITY
(Please type or print in ink) This schedule must be attached to Form OS-3105
A.
Taxpayer’s Name
C. 1. Taxpayer’s Identification Number (TIN)
B. Doing Business As
C. 2. TIN previously reported, if different from above
D. Quarter Ended
F.
Gross Revenue
G. Check ( v ) if
H. FOR OFFICIAL
E. 1. Activity
E.2.
Specify activity if code is not listed
Derived From
activity is final
USE ONLY
Code
Each Activity
for this quarter
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
TOTAL GROSS REVENUE
$
INSTRUCTIONS - The information provided on this schedule must be the same as its corresponding part on Form OS-3105.
A .
Enter the name of owner for sole proprietorship, partnership, corporation, or association.
B.
Enter the name(s) under which the taxpayer operates as; e.g. “John Doe’s Restaurant”.
C.1
Enter the Taxpayer Identification Number (TIN). If you do not have one, please apply at the Division of Revenue and
Taxation, or at the Social Security Administration. (NOTE: The Division of Revenue and Taxation will assign an I.D.
Number for use only in reporting CNMI Taxes).
C.2.
Enter your Federal Employer I.D. Number used in previous quarter.
D.
Enter the quarter ended for which you are filing this schedule.
E.1.
Enter the code (listed on the reverse side of this page) of the type of business activity the gross revenue is derived from.
E.2.
Specify the business activity the gross revenue is derived from if such activity code is not listed.
F.
Enter the Gross Revenue derived for each activity listed in item E.1. or E.2.
G.
Place a check mark (
) if the business activity is final for the quarter. (For example, the retail activity of your business has ceased during
the quarter and will not continue this activity in subsequent quarters.)
H.
DO NOT WRITE IN THIS SPACE
Schedule: OS-3105A (Rev. 1/2/2004)
NOTE: This revision is effective 4
Quarter 2003
th

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