Form 404 - Soft Drink Excise Tax Return
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form 404
commonwealth of virginia
mail to
department of taxation
dept. of taxation
p.o. box 2185
soft drink excise tax return
richmond, va 23218-2185
for the calendar year _________ or fiscal taxable year beginning ____________ and ending ____________
name
virginia account number
(name as shown on state income tax return)
trading as
(trade name if different than above)
(location of principal office in virginia)
address
(number and street or rural route)
(city or town)
(state)
(zip code)
1.
gross receipts from sales (total sales for entire business) .................................................................
2.
gross receipts not subject to tax (see instructions)
(a) gross receipts from sales other than carbonated soft drinks ......................
(b) soft drink receipts not subject to tax ...........................................................
3.
total (sum of line 2(a) and (b)) ...........................................................................................................
4.
soft drink receipts subject to tax (subtract line 3 from line 1) .............................................................
5.
tax due (see schedule of tax rates below) .........................................................................................
6.
penalty (see instructions) ...................................................................................................................
7.
interest (see instructions) ...................................................................................................................
8.
total due (sum of lines 5, 6 and 7). this amount must be paid with return ........................................
effective 7/1/02
tax rate schedule
(rates based on amount on line 4 above)
total gross receipts per firm
amount of tax
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
100,000 or less
$
50.00
100,001
—
250,000
100.00
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
250,001
—
500,000
250.00
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
500,001
—
1,000,000
750.00
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1,000,001
—
3,000,000
1,500.00
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3,000,001
—
5,000,000
3,000.00
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5,000,001
—
10,000,000
4,500.00
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10,000,001
—
25,000,000
7,200.00
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
25,000,001
—
50,000,000
18,000.00
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
50,000,001
—
and above
33,000.00
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
declaration of taxpayer
i declare under penalties provided by law that this return has been examined by me and is, to the best of my knowledge and
belief, a true, correct, and complete return, made in good faith pursuant to the provisions of the code of virginia.
date
signature of taxpayer
title
(
)
contact person
daytime telephone number
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