Maine Use Tax Compliance Program Special Use Tax Return
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1
2
3
4SPECIAL
Maine Use Tax Compliance Program
*1283000*
99
Special Use Tax Return
USE TAX
*1283000*
*12012011* *12312011*
-
If applicant is a corporation, partnership or LLC, enter federal ID number
Business Name
-
-
If applicant is an individual or sole proprietor, enter Social Security number
Initial
First Name
Last Name
Mailing Address
City/Town
Zip
State
Instructions
DO NOT use Red Ink.
List the yearly totals from the supplemental pages. Substitute worksheets will be accepted.
3 Highest Years—List years from supplemental pages
Total Yearly Purchase Price
$
1.
.00
,
,
$
.00
,
,
2.
$
.00
,
,
3.
$
.00
4.
,
,
Total Taxable Purchases
Multiply x 5%
.05
$
.00
,
,
Total Maine Use Tax Due (round to nearest dollar)
5.
3 Lowest Years—List years from supplemental pages
Total Yearly Purchase Price
$
.00
,
,
6.
$
.00
,
,
7.
$
.00
,
,
8.
,
,
$
.00
Total (add lines 6, 7, and 8)
9.
I certify that I have read the information regarding the 2012 Maine Use Tax Compliance Program and certify, under penalty of per-
jury, that all statements are true, complete and correct to the best of my knowledge and belief. I also agree to forgo the right to pro-
test or pursue an administrative or judicial proceeding with regard to the items reported on this Special Use Tax return or to claim a
refund of any money paid under this program.
Make check or money order payable to TREASURER, STATE OF MAINE. Send your remittance with your return to:
Maine Revenue Services
P.O. Box 1065
Augusta, ME 04332-1065
Signature
Date
Phone
Preparer Name
Preparer ID
Revised 07/19/12
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