Long Form - Payroll Tax Statement - San Francisco Tax Collector - 2005 Page 2

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SCHEDULE C
Payroll Expense
2005
CERTIFICATE
BUSINESS TAX ID
Tax Year
NUMBER
32074
Column B
Column A
Column C
PAYROLL TAX CALCULATIONS
Locations
No. taxable SF
Taxable
NAICS Code
Gross Payroll
Exempt Payroll
employees as of
(non-SF = 999)
Payroll
12/31/05
DBA Name and Location Address
,
DBA
1
,
,
,
,
.
.
LOC
DBA Name and Location Address
DBA
2
,
,
,
,
,
.
.
LOC
DBA Name and Location Address
DBA
,
3
,
,
,
.
,
.
LOC
DBA Name and Location Address
DBA
4
,
,
,
,
,
.
.
LOC
DBA Name and Location Address
5
DBA
,
,
,
,
,
.
.
LOC
DBA Name and Location Address
6
DBA
,
,
,
,
,
.
.
LOC
DBA Name and Location Address
7
DBA
,
,
,
,
,
.
.
LOC
8
Totals
PLEASE DO NOT TEAR APART HERE
SAN FRANCISCO TAX COLLECTOR
2005
LONG FORM
BUSINESS TAX SECTION
P.O. BOX 7425
PAYROLL TAX STATEMENT
SAN FRANCISCO, CA 94120-7425
TAXPAYER ASSISTANCE: (415) 554-4400 TTY: (415) 554-4455
PERIOD COVERED: January 1 - December 31, 2005 DELINQUENT IF PAID OR POSTMARKED AFTER FEBRUARY 28, 2006
OWNERSHIP NAME
BUSINESS TAX ID NUMBER
PAYMENT ENCLOSED
NOTE: Payment enclosed must equal the amount due on Line 16 of statement.
(Please write your Business Tax ID or certificate number on your check.)

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