Form 500-Bgrt-Bwh - Business Gross Revenue Tax And Backup Withholding Deposit Slip
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1DIVISION OF REVENUE AND TAXATION
COMMONWEALTH OF THE NORTHERN MARIANA ISLANDS
BUSINESS GROSS REVENUE TAX AND
BACKUP WITHHOLDING DEPOSIT SLIP
20
DLN
(Please Type or print in ink)
A.
Taxpayer’s Name
C. 1. Tax ID Number
D. Quarter Ended
B. Mailing Address
C. 2. Soc. Sec. No.
E. Withholding Agent’s Telephone No.
F. 1. Withholding Agent’s Name
F.2. Withholding Agent’s Taxpayer Identification Number
H. BGRT
OS-3105G
OS-3105MW
G. 1.
S 1441
CORPORATE
INDIVIDUAL
S
OS-3105B
OS-3105AF
G. 2.
OTHER (SPECIFY)
I.
Amount Deposited ..........................................................................................
$
FOR OFFICIAL USE ONLY
Receipt Number
Account Number:
Account Number:
Date Paid:
Account Number:
Amount
Amount
Input Date:
Input By:
Amount
Form 500-BGRT-BWH (Rev. 1/2004)
NOTE: This revision is effective 4th Quarter 2003.
INSTRUCTIONS
GENERAL INFORMATION:
Payment Deposit Form 500-BGRT-BWH is a form used to make Tax Deposits for Business Gross Revenue Tax or Backup withholding
of NMTIT S 1441 for foreign individuals or corporation.
S
A.
Enter the name of the sole proprietorship, or partnership, or corporation, or association on behalf of whom this deposit is
being made for.
B.
Enter the mailing address, including post office box, if any.
C. 1. Enter the Taxpayer I.D. Number. If the taxpayer does not have a Taxpayer I.D. Number, please apply at the Division of
Revenue and Taxation, or have the taxpayer apply for a Social Security Number 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.)
2. If this deposit is for an individual/sole proprietorship, enter the Social Security Number of the individual/Sole proprietor in
line A.
D.
Enter the Quarter period for this deposit.
E.
Enter Withholding Agent’s telephone number(s).
F. 1.
Enter the Name of Withholding Agent making payment on behalf of Taxpayer in line A.
2.
Enter withholding Agent’s Tax I.D. Number
G. 1. Place a check mark in the applicable box. Check S 1441 if you are remitting 30% tax deposit for a foreign individual or
S
corporation.
2. Place a check mark if G.1. does not apply and specify.
H.
Place a check mark in the applicable Gross Revenue Return for credit to be applied to.
I.
Enter the amount being deposited.
Form 500-BGRT-BWH (Rev. 1/2003)
NOTE: This revision is effective 4th Quarter 2003
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